Cynulliad Cenedlaethol Cymru

We have a problem, I think. 

I'm really sorry, the translation isn't working. It was in the test session, but it's not working now. 

Okay. In which case, hopefully this will be resolved and I'll get a message to say that it has been resolved as soon as possible. 

To start, could I ask you both to give your reflections on what you believe the impact of the pandemic is on rates of suicides, on self-harm, suicidal behaviour, and so on? Who fancies going first? Sarah.

Yes, go on, Sarah.

Thank you. So, I think there are two things here, really. One is around the numbers and around the impact on suicides. The answer is that we don't know, because we don't have that real-time data, which is one of the points that we made in our response—that it would be very useful to have better, much more up-to-date live data. And I think that there are some improvements around that in terms of the regional forums, where they have contact with the police and they have a much more immediate picture of this. But I also think we need to be really careful about how we talk about increases in suicide as being a natural response to this kind of big crisis that we've all been facing. It's not an inevitable result. We've seen some interesting things around the resilience of the ways that people have responded early on in the pandemic. However, we do have cause to be really concerned. My second point is that we know that the pandemic and the response to it is disproportionately affecting the most vulnerable people in our society, and it's exacerbating factors that we know are related to suicide—so, those include loneliness, isolation, lack of belonging, lack of meaningful occupation, and all sorts of other issues around people with pre-existing mental health problems. There's evidence emerging that they are disproportionately impacted and struggling as the restrictions continue. So, it's not inevitable. There are a lot of things we don't know, but we do know there's a big issue around inequality here, and disadvantage.

And Kate Heneghan.

Yes, I would agree with Sarah. We don't know what the figures are. We can't know yet—there's always a time lapse. But we shouldn't be waiting to hear what the figures are; we should be mitigating the risks anyway. We do know it's a fact that, following the global financial crisis of 2008, we saw an increase in self-harm in young people, we saw an increase in suicide rates. We're likely to have a huge economic impact on our population as a result of COVID, and therefore we must be mitigating the risks.

I would also like to add that, before COVID, we had concerns about suicide rates increasing, in particular in young people. So, in those 15 to 19-year-olds, we were particularly concerned, and the rate since 2010 had been increasing. So, we had valid concerns and we were looking into these things. Now, possibly, what has happened during COVID is that we haven't really put into place what we needed for people with mental health problems right from the start, because obviously there were other things that were calling our attention—for example, personal protective equipment. We've almost forgotten that there was a need, a crisis around that. But what we are seeing is that with the effects of COVID, particularly on people who had existing mental health illnesses, those illnesses have become worse during this time. We had a very good campaign at the start, 'Protect our NHS', 'Look after our NHS workers', which worked really well, and what we were hearing on our helpline was people saying they didn't want to burden the NHS. Obviously, Welsh Government said that mental health services were still open, but maybe what we need to ensure is that those messages are clear for the people who need them.

I also feel that the support for families—. We've had lots of calls from concerned parents who have been struggling themselves during COVID to look after young people who were struggling, not knowing where to go for support. So, we really need to look at that as well.

Just to dig a little bit deeper on the data and the lack of data that could give us a real sense of what's going on, there is work going on—we're speaking with Professor Ann John later in this morning's session on the work that she's doing feeding into the technical advisory group, and we know that patients are presenting at accident and emergency for self-harm, and data is being gathered on that. What more could be done to try to give us a picture of what's going on, especially given that with things like the data on self-harm there's nothing to compare with, because this wasn't being collected prior to the pandemic?

Sarah.

I'm well aware of the work that Professor Ann John is doing to improve data collection. It's just really important, and it's great that you'll be hearing in more depth from Ann on the work that's going on there. I think, yes, the live data is really important. Also, we could be understanding more about trends and prevalence, for example, in different ethnic groups. So, I think there's more granular data that we could be collecting, for example. Where we don't have comparable data we just don't have comparable data, I think. We just need to start doing it now. 

Lastly, to reiterate what Kate just said, we actually do know a lot of the things that we need to do to mitigate suicide risk in the population, and we shouldn't wait. We should act on what we already know. There were already big challenges around the levels of self-harm, big challenges around getting mental health support. So, we know things already, but the better data would be a big step forward as well. 

And Kate Heneghan on that data issue. 

Yes, both Sarah and I sit on the national advisory group with Professor Ann John, and we're aware of the great work that's going on around real-time surveillance. Numbers are small in Wales, so that is another factor. A study has happened in England, and I'm sure that Ann will talk to you about that. But we need to be better at communicating—we need to have some sort of central point where suicides are reported into because, as we well know, if you are bereaved by suicide, you are then at risk of suicide yourself. So, a lot of work needs to be done on that, but we are on to it; it's just about whether that can be accelerated now during this COVID time. 

Just one last question from me there. You mentioned work that's going on in England and the comparison with Wales. I think there was a suggestion last week in the committee—forgive me, I can't remember which one of our witnesses said this—that perhaps stronger basic support networks in Wales meant that perhaps we weren't seeing the same impact in this area as in England. Do you have any evidence to support that? 

Sarah.

No, I don't think so. I'd be very cautious about that because we just don't have the information. Back to the point, we know the sorts of things that we need to do. I would not want to create any sense that we've somehow got things better, because we don't have the evidence to back it. We may have some areas where community is stronger, but we don't have that sort of evidence that I'm aware of, anyway. 

Thank you, Chair.

Andrew R.T., you've got a supplementary here. 

Thank you, Chair. Sarah, you introduced the rich tapestry we have in our communities, and coming from South Wales Central, I probably come from the most ethnically diverse community in Wales, covering Cardiff, the Vale of Glamorgan and the Valleys. Is there greater work needed to understand the help and support that needs to go into BME communities, because, obviously, there could be issues that need to be tackled more sensitively? 

Sarah.

Thank you. Yes, I really do think there's more work that needs to go on there. We don't actually have the basic data around suicidality that is broken down into different communities and different ethnic communities. To pick up your point about the diversity in the community, one of the things—. We did a report on disadvantage a few years ago, and one of the things that was picked up in that report was the link between a lack of sense of belongingness to your world and the risk of suicidal ideation and rumination, and that sort of thing. So, I think community and connection and a meaningful contribution to your world is really important for emotional well-being, and those community infrastructures are incredibly important and especially—. Obviously, the Samaritans is a voluntary organisation—we have an incredible volunteer cohort and so do many others, and I think volunteering is a great way of connecting with your community. We've seen all these lovely seeds spring up over the period of COVID and I think we need to nurture and support all of that, at the same time as recognising the big economic shock that people are facing. So, I think it's not one—. It's definitely not one solution to this. There is employment, there are all sorts of other community connections, and we need to act to support all of that now. We know that that's good for everyone, anyway. 

Okay. Before we carry on, Sarah, our very clever beavers behind the scenes are working on the translation stuff, and they're asking can you go down to the globe and click on 'English' as regards the interpretation again. See if that works now, okay? Kate, did you want to add anything to that last question from Andrew R.T. Davies? Sorry, you're muted. 

Sorry. Thank you, Andrew. Just to say, really, that stigma is huge in different cultures and faiths; they look at suicide in different ways. Sometimes, getting information through to those communities can be more challenging, but that doesn't mean that we shouldn't be trying, and there is a lot more to do. 

Could I just, Chair, take one more point just on that? Language is really important, and there's a multitude of languages spoken in the city of Cardiff, for example. When help and support is in place, how confident are you that we meet the language challenge for that particular community in the services that Government and the volunteer sector in Wales provide?

Who wants to kick off? Sarah, go on.

From my own organisation's point of view, I don't know the answer to that straightforwardly. But I do know that, in Cardiff, for example, our Cardiff branch is reaching out into different communities. For us, it's not just a question of having services there; it's a question of them feeling that they are there for you, that they're relevant. And that's why you need to reach out and work with organisations that do have reach into all sorts of different communities, and that you're giving the message in the right way. So, I think it requires energy. I don't really like the term 'hard to reach'; I think, actually, it's incumbent on us to be demonstrating that we are relevant and that we can speak to people where they are. So, I think we all have a lot of work to do. And it's never been more important, actually; it's never been more important to do the really simple thing of making people aware that help is there, that it's good to seek it, that it's relevant for them, and that it can help. 

Kate, in addition to that.

I would just say that we are looking into translating various resources that we have for those communities. It's an ongoing programme, but it's really important that we get this right. And, obviously, we know that the black, Asian and minority ethnic community have been hardest hit as well with COVID, so that's an additional problem. 

Thank you, Chair, and good morning. Just following on from the questions that Andrew's asked around black, Asian and minority ethnic groups, there's other ways that—. It's important that the documents are translated into different languages, but also, there are many groups who don't read leaflets or take their news in that particular way. I'm just wondering if there's different ways of communicating with those groups, whether it's videos or people who are perhaps prominent in their communities—that you're able to access those groups of people to get the message out a little bit further. 

Kate first this time. There we are, I'll vary. 

We were lucky enough to get some funding from the Welsh Government recently for suicide and self-harm, and we bid successfully for some moneys for training in the Cardiff area. Face-to-face, sadly, at the moment, isn't happening, and so we're looking at working with those communities on some sort of online training. And you're absolutely right; working with the community leaders is paramount in all of this. 

Great. And just in terms of—we've talked about and you've talked about this morning the disproportionate impact it's had on different groups. As we're moving through the pandemic, do you think that there's targeted action needed for certain groups, and what do you think that could involve?

Well, I think, certainly for children and young people, now that they're back in school, they're back in that safe environment. For a lot of young people, home hasn't been a safe environment. They've got trusted people around them. So, we have to make sure that there are services available through schools for young people that they can use. We also—. Sorry, what was the other part of your question? I'm so sorry.

I was just wondering about some of the groups—the disproportionate effect it's having.

Oh, yes—disproportionately affected. Yes, sorry. We are getting lots of calls from people with very complex mental health needs. So we feel like that is a group that really needs support, to make sure that they are aware that services are open and they are available. And maybe we need to be looking at other ways that we can reach them as well, instead of—. We're assuming that everybody can use digital, and that's not the case. Many people with complex mental health needs, they want that face-to-face, and we need to look at how we can do that as well—walks in the park, things like that—instead of making everything digital. I think we relied on that too much, and we need to look outside of that box, to be there to help them.

Sarah, and then we've got Lynne with a supplementary. Sarah.

In relation to reaching out to different communities and different ethnic groups, we've got work we're doing on equality, diversity and inclusion, which is about changing and improving the face that we're showing, both in terms of volunteer recruitment, but also how we're advertising ourselves and the sorts of messages that we're giving out. But I would also, just to pick up on the point on mental ill health—in half of the calls that relate to COVID-19 to Samaritans, mental ill health is a major feature. It's exacerbating existing mental health conditions, people are reluctant to seek help, or it's not available as it used to be. And I would just reiterate what Kate said about assuming that virtual is a substitute entirely for the kinds of contacts that people were having. And I know that's a difficult truth, but I think it is a truth—that it's not suitable for everyone. And I do think that the evidence that we're seeing from our survey of volunteers, and what they're hearing, is that a big feature of the impact of COVID is the impact on people with pre-existing mental health conditions. And we're really concerned about that. We see a significant increase in anxiety, for example, coming through to us, and that's continuing.

Lynne Neagle.

Thanks, Chair. Good morning, both. Kate, you said in response to Jayne that children were back in a safe place in school and that, for lots of young people, home isn't a safe place. Can I just ask both of you: how important is it that we keep schools open for young people's mental health?

I think there's no doubt now that the evidence is showing that children and young people have been disproportionately affected by this pandemic, and they've been the ones that were least likely to suffer from physical illness from it. And we've learned that—we didn't know that at the start of all of this; we know it now. And we know that loneliness and isolation, away from their peer groups, are huge things. So it is paramount that schools remain open throughout this, in my opinion, and the evidence shows this.

And Sarah.

Yes, absolutely. Before the pandemic, we did a report on school exclusions, and on the long-term impacts on young people of that, and asked that there should be a lot more attention paid to keeping and holding young people in their school community, because of the long-term damage that is done to those young people—it exacerbates existing disadvantages, existing challenges at home. So it both shines a light on the generality of young people and the importance of them being within a school community, but also on those young people who are either on the verge of exclusion or already excluded. And I would really make a plea for them, that they aren't forgotten in this, because they are the most invisible—and could possibly become even more invisible to schools. I would be very concerned about the situation of some of those young people, and I think we need to be quite vigilant about what's happening with them.

Excellent. Andrew's got a supplementary.

If I could just take the point that you made about it being of paramount importance to keep schools open, obviously, regrettably, we're learning today from Northern Ireland that they're already announcing the closure of schools in a circuit-breaker lockdown. Would your advice be, even in that situation, that schools should remain open, given their importance to the well-being of the child—their mental and physical well-being?

Yes, I would say that, definitely. We have half term coming up, don't we? And I know that, in Powys, there's a two-week half term because they went back slightly later. Maybe extending the current half term to two weeks as an interim measure would help with that circuit break, but I certainly would not want to see schools close in the same way that they did during the lockdown. 

Thank you. That's helpful.

Okay. Jayne, had you finished your questioning? Yes. So, moving on—David Rees.

Thank you, Chair. Good morning, both. Following on from that in one sense, because as children move from school, they go into universities. Now, we all understand that university has always been a challenging place for some people as they go away from their support network and their home environment into a different type of environment, which is, for some, very challenging. We're seeing students go back to university now. With COVID-19, however, there are different environments at university, which possibly cause even more difficulties for some of those individuals.

You've also talked this morning about the fact that we should be taking action now and moving forward. What advice can you give, perhaps to the Welsh Government and to universities, to say how they should be supporting students in this situation? And secondly, the advice has been from SAGE that they should all go home and be taught online. Is that also, considering what you said about schools, a valid option or should we actually be looking to ensure that we create that environment in the university—a safe environment—but at the same time take the right measures to protect those individuals who may find difficulties and challenges?

Who wants to kick off there? Sarah.

Thank you. It's a really important issue, this, around the universities. I think there's obviously the bigger decisions that are being made public health-wise about, 'Go or don't go to university', but whatever the situation, I think there are certain things that can guide us. So, yes, we're very concerned about young people with the additional stresses, potentially, of isolating within a flat and being away from home for the first time. I think I would say be proactive about letting young people know about sources of help and be compassionate; have messages given out to students that are respectful, compassionate messages that recognise the challenges that they're facing. 

I would also say involve young people in the decisions that are being made, because we know that having choice and control over what's happening to you is a key, important thing around your own sense of well-being. So, respecting the rights of young people in this situation—all those are really important. It's hard to produce a blueprint about how universities should be responding, but I would say be guided by compassion and be proactive—be proactive in terms of the messages being put across to students and how those policies are being shaped and recognise, right at the top of your agenda, the threat and risk to young people's mental health and well-being.

Thank you. Kate.

I would agree with Sarah there, absolutely. I think, as a parent, during those first couple of weeks, had I had a child in university, I would have said, 'Go and get them, bring them home'—it's your instinct; it's what you want. And I have thought, maybe the student population, again, are ones who don't seem to be suffering from COVID when they get the illness, and I wonder whether maybe we should keep the lecturers at home and let the young people be there. Maybe that is what we should be looking at, thinking outside the box.

We are getting a lot of calls from students who are lonely and isolated and struggling. We're getting a lot of calls from parents who have sent their young person off and they are pulling their hair out because they are worried sick. And we are getting calls from responsible students who are worried about other students. Now, I think maybe there's a lot to learn from that. Students are responsible people, so let's start looking out for others—you're all in this together, be sensible in this situation. Papyrus has got this 'Suicide-safer Universities' guide, which we did in conjunction with Universities UK, and that is known to universities, so it's about maybe accelerating some of the stuff that's in there as well, and certainly making sure that they are aware of the numbers that are available—of helplines— out of hours when they can't maybe reach welfare. We always say in Papyrus, 'Put our number in your phone. You never know when you might need it; don't wait for a crisis to happen', and I think that's really important as well.    

Can I ask—? Just on this final point of this, we all understand the challenges that faced students before the pandemic and the situation beforehand. Have you seen an increase in responses from the universities to the additional pressures COVID will put on in this area? Because they've taken these young people into university, they go into halls, we are seeing a large number perhaps actually get COVID as well—have universities stepped up their programmes in this area? Sarah. 

So, I can't—. I would not want to give an assessment of that, really. We have done proactive work with the universities and had positive responses in the past, pre COVID, and during it. So, we've got an education compassionate response toolkit, for example, and my experiences of them previously is that universities have been really keen to receive the information that we've been giving them. But, in terms of how they're reaching out, certainly I'm not aware of an assessment of how they're doing that at the moment. 

Kate. 

Just to say that we have had some conversations with some of the Welsh universities at the moment about getting some information out to them, but, like Sarah, I wouldn't be in a position to comment further. 

Okay.

Thank you. 

Thank you, Chair. Can I first of all ask about access to services? Kate referred to the assurances that have been given by Welsh Government that mental health services continued throughout the pandemic, and that's an assurance that we, as a committee, have been given. But what we, as a committee, have found is that there is a big disconnect between that assurance and what seems to have happened on the ground. So, I'd like to get both of your views, really, on whether, in your understanding, the whole spectrum of mental health services has continued during the pandemic. 

Okay, who wants to kick off? Kate. 

Well, from what we're hearing on the helpline, we are hearing about people's whose appointments have been stopped; we're hearing about how they—. Sorry. So, appointments have been stopped, they cannot access the services that they're used to accessing, they have to wait. We're hearing from people who say they can't wait, they won't wait; it's really difficult for them. We're hearing from parents who are telling us that their children were about to be—they were in the system, ready for a diagnosis, and it had been stopped and they really were struggling to cope with looking after their young person at home. So, it feels like it is across the spectrum, to be honest.

But we are getting an awful lot of calls, as I said, earlier, from people with very complex mental health needs that are not being met at the moment. So, I think that the interim measures that were in place were inadequate, and we really need to work on this now to make sure that we have better services. We know the situation. There are no excuses now. We need to make sure that services are open—the messaging is out there—but that the support is there. 

We had one young person who called us. They were known to mental health services, had a crisis team. They had phoned their crisis team 38 times without a response. So, it feels like maybe crisis teams, even when people are known to them, that they're putting more boundaries in, and that is proving very difficult, and a lot of people, young people in particular, are struggling. 

Sarah, any addition? 

Yes. So, I think, even before the pandemic, there were some issues about how ill, how desperate, people need to be in order to access services in the first place. Certainly, what we're hearing through our helpline is—. So, a sense of helplessness, distress and entrapment about lacking or inadequate access to mental health services and worsening mental health remains a strong theme and are raised as frequently as in the second month of lockdown. So, that's the third month assessment, and that's continued.

So, I think—. People are coming through to our helplines who—. We've always been the thing that is there right around the clock and at weekends and in the small hours of the morning. So, we get that from people who are not able to access services during the day. We are hearing more about lack of access to mental health services, and I think there's certainly cause—. It certainly raises cause for concern around whether, actually, people are being able to get the services that they would even usually have had access to. So, I would be worried about that, and also worried about how confident one could be, actually, that people are having their services as usual, because I think that what we're hearing is that people are experiencing real difficulties there.

Okay. Lynne.

Thank you. In terms of crisis care, which you've referred to, how effectively—? Kate mentioned a very bad example—well, it was a good example of bad access to crisis care. Is that a uniform thing that you're seeing, or are you seeing people able to access the crisis care that they need in an emergency?

Kate.

Well, we tend to only hear from those who aren't accessing—that's the truth—the ones who are at their wits' end. But it feels like child and adolescent mental health services thresholds are very high for risk. Getting people to actually be seen, we're hearing, is not easy. We are also hearing from our social services friends that they are reaching a point where they feel that they're struggling under their workloads as well, having very complex cases to deal with, and that, obviously, isn't helping the situation.

Okay. Sarah. 

So, I don't really have a great amount to add to what Kate has just said, because I think—. As part of the Wales Alliance for Mental Health, we have regular discussions with the Welsh Government about these things, and I think there are issues around alternative places of safety, for example, about the suitability of accident and emergency, about the—you know, all the pre-existing challenges, I think, have been exacerbated by the COVID-19 crisis. Also, as ever, there's a lot that we actually aren't aware of. But, certainly, I think that we need to explore how crisis care is going, and that would be good thing to look at in the next cross-party group, actually, on this subject, where we're going to hear from Mind around how alternative—. For example, this question about people not being in police cells, having alternative places to go—that's a really important thing. There have been big improvements around that, but what we need to know is how the alternatives are actually working for people.

Thank you. Lynne.

If I can just ask specifically about self-harm then, rather than talking about the services, which we've just explored, Samaritans's consultation response says that people are finding it more difficult to manage their self-harm because of the pandemic, because the kind of support mechanisms, distractions et cetera aren't available to them, given all the restrictions. What should we be doing, do you think, to address that? And it's also about not medicalising distress, isn't it, really, and not automatically putting people into services. So, what are the options that we should be looking at, do you think?

Sarah.

Thanks, Lynne. So, in our response, we talk about better online support. It's a good idea anyway, but, just pragmatically, in the current circumstances, that would be a really good thing—to develop better online support and better awareness of that. There are other things as well. Samaritans has held a round-table with various experts and people with lived experiences quite recently in Wales and we've done research across the UK into self-harm. One of the things that has come through that is, where people reach for help, they very often reach out to friends and family. Schools are really important places. So, I think more information for the general public, more information around how you respond compassionately to people who are self-harming, is just really, really important. So, the online support, the information and the first-line response that you get. And the other thing that has come through to us is, as I mentioned earlier, that the threshold for help is quite high, and often—. So, just judging people by the amount of self-harm they're doing in terms of the seriousness of the distress that is driving it is a connection that isn't necessarily—. It can be misleading; people can be in extreme distress and really need help, but because the barriers are so high—. So, I think we need to really look at that and we'll be producing a report on this very subject quite soon, and that will almost certainly be one of the things that we're recommending.

Okay. Kate.

Yes, I would endorse what Sarah has just said, and, just to add to that, let's not forget the parents here as well. Papyrus have just brought out a guide for parents, it's called—it's around suicide and self-harm, and it came about because parents who lost their 15-year-old son to suicide said that they found themselves quite often in A&E departments, at the doctor's surgery, or in the chemist waiting for a repeat prescription, and in all of those places there was never any information around suicide in particular. We did a little bit of research into this talking to other parents, and what they said was, 'Do you know what? If it just said "suicide" on it, I don't know if I'd have picked it up', even though their child later died of suicide. So, there's huge stigma still around suicide. So, this leaflet—. We included self-harm in it—the intention was for it just to be about suicide—and this has come about because there is a need there. So, let's not forget the parents. The parents and the family can be huge support. So, getting that leaflet out there is really important. So, if any of you want more information about that, please let me know. But there is—. I can't reinforce enough how important the stigma is. Suicide is all of our responsibilities. We need to be able to talk about it in a sensitive and respectful way that is safe.

Okay. Lynne.

Thank you, and just to say that the leaflet for parents is really excellent, Kate. Thank you for it.

Thank you, Chair. Earlier, you mentioned that bereavement clearly is something that can cause individuals to find themselves in a situation that is deep and dark. In 2019, the Welsh Government had a review and published a report on the review, pre-pandemic. What actions are you seeing being taken as a consequence of that report and are they sufficient, actually, to support people through bereavement at this point in time? Because, clearly, there are many more people that have, unfortunately, passed away as a consequence of COVID-19 than would normally have passed away. So, we're in a situation where we're seeing high levels of expected deaths as a consequence of this. So, where is the bereavement support at the moment, in your eyes?

Okay. Sarah.

One of the responses from the Welsh Government was to create a bereavement pathway, and I know that there's a new national co-ordinator for suicide and self-harm prevention, who is working on that. So, I think—. As far as I'm aware, there's work under way to improve the local response, and we need to recognise that—that's good, that's a step forward. Are we where we need to be with the really consistent joined-up approach and we can be sure that everyone who is bereaved by suicide is offered the support that they need? I don't think we're in that place. I think it's still patchy and I think there's still a significant way to go. And it is really important, obviously—. As you've already said, in a sense, bereavement support for those bereaved by suicide is suicide prevention. It should be part of that. So, a way to go, but there are some moves being made in the right direction, I would say.

Kate.

Can I just clarify, it's not being lost in the overall consideration of bereavement support, because clearly, the large number of excess deaths; it's not being lost in that, is it?

Sarah.

So, the national co-ordinator is the national co-ordinator for suicide and self-harm prevention specifically, so the bereavement pathway, as I understand it, is specifically around bereavement by suicide. And your point is a really important one, because there are very specific issues for people who are bereaved by suicide. It's a particular kind of bereavement and we need, for example, 'Help is at Hand' to be available, which is a very good guide and support booklet for people. We need that to be given to people systematically; everybody who would need it. That's not, as far as I'm aware, happening at the moment.

Kate.

Yes, I agree with everything Sarah has said there. We are trying to accelerate now some of that work around the bereavement pathway, and maybe it needs a little bit more of a push, actually, and we're not where we want to be, certainly, but it is being looked at and it is being addressed. The 'Help is at Hand' leaflet, the booklet that Sarah mentioned, is also going to be reviewed, I believe, but Ann John will probably tell you a bit more about that later. It is interesting, though, because it's a really good resource, 'Help is at Hand', but quite often we will come across people who've been bereaved by suicide and they haven't had a copy of it, so it's still one of those things that, somehow, there's a disconnect, and we need—. So, I suppose what I'm trying to say is, quite often we've got the good resources, but somehow they're not getting to where they're needed the most, and this is the thing around the guide we mentioned earlier that Papyrus have brought out, for parents around suicide and self-harm. There are some really good resources out there. Let's just make sure we're getting them to the right places.

Okay. David.

No, that's it. I suppose I understand what you were saying about bereavement from suicide. I also want to try and ask the question, because COVID has highlighted there's a different type of passing away, in the sense that people have been in hospitals by themselves, isolated; their families haven't been there. Families have been excluded to a certain extent. And as to whether you've got any anecdotal evidence as to whether this has created another rise in challenging people.

Kate.

I think it has. I have some personal experience of that. I lost my brother-in-law during COVID, but it wasn't actually COVID, but he was in a home and his family couldn't visit and his daughter was pregnant. And, you know, there were all sorts of things going on. So, a lot of people are in that position, and bereavement, it's a natural reaction, isn't it? We all grieve when there's been a bereavement, so the grief is the natural reaction. We don't know, really, what the impact of COVID is, and deaths happening in a different way, what the impact of that is; that's the truth. We can only be there to support people and to tell them that they did all they could, and that their loved ones were very well looked after wherever they were, and all of that, and just be there for people.

Sarah.

In our survey of the themes coming through to our helpline, COVID-19 featured very quickly as being about a third of our calls where it was a presenting issue, and there were a lot of things behind that, including bereavement. We haven't got a separate theme that's come through around bereavement by COVID-19 specifically. So, it may well be that we get calls from people who have experienced that, but it's not come through as a—. It will sit underneath the general, the worries and the distress on all sorts of different levels from COVID-19, rather than being a thread that we've picked up specifically. But I do think it is something we could see, anticipate and understand as being a significant feature for quite a lot of people.

Thank you.

Yes, I think that's an important point because, obviously, as you said, Kate, grief is a normal reaction, plainly, but it's grief happening in an abnormal situation now, because the normal societal way of dealing with it is to go around and have cups of tea and meet friends and people popping into your house all the time, and you'd have been to see them recurrently in their final illness—things that aren't allowed to happen anymore. So, presumably, your antennae, both of you, are up for situations where we'd expect a different grief reaction or a more serious grief reaction, because the normal societal ways of dealing with normal bereavement just can't be allowed to happen. Kate.

Yes, I would agree with that totally, to be honest. As Sarah says, bereavement is a constant theme that comes through—pre COVID it was; it is one of those triggers for people. But whether this, as Dai Lloyd has just summed it up really well there—. I haven't really got anything else to add.

Good, good. Sarah.

Hello, can you hear me?

Yes, carry on.

Okay, you can hear me. Okay. So, I think it's a very good point. In my previous work, I used to work with older people, and the concept of a good death was a really important one. There was a fantastic checklist I remember of the kind of things that you—. Until you've been bereaved, you don't necessarily realise that someone can have a good death, but I know that now, I know that you can have that. And the features of it, which include being there, as you've said, a lot of those have been impossible under COVID-19 restrictions. And so, we should be really concerned about the lack of the features that you would want when someone is dying, and I think, yes, we should be vigilant for the impact of that on individuals and on communities as well.

Okay. Are you done, David? Yes. We'll move on to the last batch of questions, then. It's Andrew R.T. Davies.

Thank you, Chair. Thank you for your evidence so far, witnesses. I'll combine the two questions I've got, because they feed into one another really, they do. Sadly, we can see the COVID pandemic continuing into the future now, and over the last six weeks—six months, sorry, not six weeks—six months, we've learned of new ways of working, in particular in the fields that you specialise in, both of you. Can you give the committee a taste of those new ways of working that maybe could feed into suicide prevention, self-harm prevention strategies, which we now need to be reviewing and adapting to take account of the new landscape? Because, obviously, as a committee, we'll be forming a report and making recommendations, so if there were issues that you wanted to leave with us that would form the basis of some of those recommendations or thoughts of the committee, now is your chance, really, to put them on the record.

There we are. The power to form recommendations for Government, team; who wants to kick off? Sarah, first of all.

Okay. Thank you very much. All I'd do is to reiterate some of things that we said at the beginning of our evidence, which was the importance of understanding this, not just as a mental health crisis, but as a population level trauma. So, in terms of new ways of working, I think it may be an opportunity to break the mental health and emotional well-being understanding into the wider portfolios that others hold. It's never been more important that the messaging from Government recognises the impact on the population emotionally, both in terms of just acknowledging it—acknowledging the sacrifices that people have made—but also recognising the very real risks there are in the economic downturn and in the need to keep people occupied, in the need to look at young people, and the need to look at all of those consequences beyond health and social care. So, I would say that very much so.

From our own organisation's point of view, Samaritans has been able to keep our helpline functioning, but we haven't been able to do the outreach, which is so critical, especially for vulnerable places, vulnerable people. So, we're concerned about that and we're looking to how we might find ways—other ways. In north Wales, for example, our Bangor branch has been driving their van around, just so that people can physically see that we are there for them, to try to have a visible presence in communities, because we are very much missing the opportunity and the chance to be physically out there, where people are. So, just a couple of thoughts from me. But, population level distress, don't medicalise it. That's a really important message, I think.

Just before Kate comes in, if I could ask you, Sarah, to maybe confirm or enlarge on that point of a cross-Government approach to this. Would it be fair to say that, prior to the pandemic, many of the issues that you were championing would just sit firmly in the health and social care portfolio, and that cross-Government approach wasn't there? So, when we build back better—which seems to be a term that is thrown around quite regularly by Ministers from all Governments, whether it be in Westminster or Cardiff Bay or Edinburgh—that cross-Government support would be one of the cornerstones that you need to embed in the thinking of Government when it comes to suicide and self-harm prevention.

Absolutely. We've been calling for a long time now for a poverty mitigation strategy, for example, that crosses all the different portfolios, because it's just so—. A lot of the things that impact on public mental health don't actually sit directly in—. Obviously, the mental health services are critical, but there are other things around community, which we talked about. Community: the issues around loneliness and isolation; the issues around young people and school and school exclusions; the issues around inequality; the issues around BAME communities. Those things sit beyond health and social care, and so does employment and training. So, I think that we have a real opportunity here to look much more across Government at these things, and I think that everybody benefits. The whole economic project for Wales benefits from positive mental health and positive emotional well-being.

Kate.

Yes, I agree totally with what Sarah has just said. It worries me sometimes; it feels like suicide is left off the list. Mental health is there. Many people who die by suicide aren't known to mental health services. We know that. That is a fact. Suicide is not exclusive. So, we do need to be looking across Government around this. Do you know what? Just think about that energy that went into planning for COVID right at the start. Let's get that energy right now, and let's use that to plan for better services, but also make sure that suicide is included in there. It is so important.

Some of the things that we could do: keep talking to children and young people. For me, that's a passion. There was somebody on the Welsh news last night, and there were a couple of things that they talked about. For the first time now we can see that unemployment rates are increasing—the first figures have come out—and that is worrying. We had a young person talking about university and he was saying that he's got his A-levels next year. Can we please look at maybe not having the exams? Let's look at different ways to support these young people, who have been through enough. Let's talk to education—schools and colleges. There must be different ways without having to look at exam results to get people into university. Let's go back and look at interviewing. Let's think outside the box for this cohort, who have been through a lot, and it's continuing. So, those are key things.

I think, as well, work around the families. Families are really important. If parents are supported, they are there to support their children. Sometimes, if a child is in the middle of a crisis that has come from nowhere, parents really don't know how to respond. We need to be there for the parents, and they need to know where they can get support as well, so they can support their young people.

Crisis teams are essential because there are a lot of people out there with complex mental health illnesses, and crisis teams are the thing that get them through. But, we need to be careful about how we manage that during COVID because things are different. We need to be able to respond to that and be ready for it, and make sure that there are sufficient services for the people who need them, and at the right time as well. That's crucial.

Again, it's that financial support for families. We need to look at that. There's been a lot of talk about apprenticeships and things for young people. We need to keep those on the agenda as well—all of those things. And we can do it, we can mitigate those risks that we know are there and accelerate the plans. We've got suicide prevention strategies. Let's keep working on that—let's not wait to see what the figures are, but keep doing what we're doing, and, together, we can make a difference; I know we can.

Could I just ask, on the point that you made, which is a really important point, about people who've never been captured by the system who commit suicide? The amount of people, sadly, at 52 years of age, I can think of, back in time, who have taken their lives and the conversation was, 'I never thought they would've done that', on the basis that you assumed that they were happy people, content in their lives—. Is there—? Perhaps 'system' is the wrong word, but can the system respond to those unidentified individuals? Because, if anything, COVID-19, regrettably, will see an increase in that cohort of individuals just by virtue of it's a left-field occasion—no-one could've planned for it, no-one could've seen it coming, and the scale of it is a society-set scale, across all sections. So, is there a model that you can build into the services that are provided that can try and identify people who might be susceptible to suicide and, obviously, assist and help?

Well, what I would say is that we need to work towards suicide-safer communities. Within that, I would also want to see more training for key people. But do you know what? Papyrus do a lot of suicide prevention training and we've had bereaved parents on that training and they say things like, 'Why didn't we know about you before?', 'Why didn't I come to training like this before?' So, we need to make that, as Sarah said earlier, population-wide. We need to be having that conversation around suicide and around what the risk factors are and what we can look out for. And we need people to be not stigmatised around suicide and to be able to ask that question, 'Are you having thoughts of suicide?' and to mean it and then to know where to refer those people, even if it's a phone call. The answer, Andrew, is 'yes', there are things that we can do to help that, and it is about a national conversation around suicide.

Okay, thank you.

Lynne had a question. So, Lynne.

Yes, thank you. Last week, the First Minister announced that there would be a new Minister for mental health and well-being in Wales. The responsibilities of that Minister were circulated to Members of the Senedd yesterday, and 'suicide', the word, just isn't even mentioned at all. So, I'd like to get your response to that. Obviously, in England, there is a Minister who has explicit responsibility for suicide prevention. Do you think that this is a missed opportunity in Wales?

I'm sure that Sarah and I want to scream at the screen, don't we? [Laughter.] Yes, it is a huge missed opportunity—of course it is. And we want suicide on that list, please. How could we do it? We will lobby—Sarah and I will be down there with our banners outside the Senedd.

Well, the new Minister is, I think, in front of this committee shortly. Sarah.

Yes. And I will look forward to meeting the new Minister. It's really important that suicide is specifically mentioned and referenced. And one of the reasons for that is because of what we've just been discussing—that it's a whole-population issue; it is about everybody knowing about sources of help. And it crosses so many different boundaries. You could say that all mental health issues do that to some degree, but I think that suicide, particularly, is a public mental health question, and it needs to be specifically championed and referenced.

Excellent. A final question from me, really, on the back of suicide, which, obviously, is an acute mental health emergency, and sometimes, for the days and weeks beforehand, there have been hints of escalation. Whether they've been to see their GP or not, certainly words have been mentioned to families and such. So, there's been an escalation in mood, but there's a real issue, certainly in primary care, from a general practice point of view, of actually gaining access to acute mental health emergency provision. Yes, we have crisis mental health teams now. Back in the day—because I'm very old, obviously—back in the day, we could ring the psychiatric doctors on call and gain immediate access from primary care to secondary care psychiatry, and they'd be seen and assessed, basically, there and then. That's no longer available; it hasn't been for about 10, 15 years. Crisis teams are very good when you can get hold of them and when they can get hold of you and/or your patient, but it's not that immediate response. Now, we don't tolerate a lack of an immediate response to an acute physical emergency, like heart attacks and stuff—you would expect your GP to ring up the cardiac guys in the hospital and say, 'Let's see him now'—but we tolerate a situation where we can't do that for acute mental health emergencies.

In terms of recommendations from this committee as regards mental health services, we can't just go back to where we were pre COVID. Let me allow you to formulate another recommendation of how we are going to be in charge of mental health services after this pandemic. I don't know who wants to—? Kate, you were into crisis teams.

Yes, that is a difficult one, Dai. My husband's a GP, and, since I've worked for Papyrus, I've given him our number and he's got the cards in his office, and, when he has a young person in front of him and is referring them to CAMHS, to keep them safe for now, he'll give them this card and say, 'Phone that number when you're having those thoughts of suicide or you're struggling.' Because, as you say, you cannot just, as a GP, pick up the phone now and just get that support. I think we need to be looking outside the box again around this. There are—. Obviously, Sarah and I are both here representing our organisations, and we are here to help in those times, but we need more than that for a lot of young people.

I know that counselling services, talking therapies, that sort of thing—I know that Mind and the Wales Council for Voluntary Action have looked at a model, haven't they, during COVID, so that access is available. I think it's self-referral or through them, but it's not using the GP model. So, maybe there are ways of looking at that, and let's evaluate that. It seems that lots of people have gone through that system. Let's have a look at that and look at different ways of getting people support immediately where—perhaps they can't access their GP in the same way that they have been able to, so even that is going to be more difficult.

But I would say people need to know where they can access support right now, absolutely. One of the things that we've introduced, during the summer, is safety planning for people who phone up when they are struggling with thoughts of suicide. So, that is something that we can go through with somebody, and there's an electronic system now where they can actually access. If a young person phones up and needs to go through safety planning, we will do this with them and then they can access that. And we've got some evidence now to show that they are actually accessing it after the telephone conversation. So, we do need to be thinking—. Knowing what's out there—. Again, as I said earlier, sometimes there are lots of good things going on, but it's about bringing them together and making sure that there is something for somebody at the right time.

Excellent. And the last word to Sarah, then. Sarah.

Yes, I would agree with all of that. We know a significant number of people who go on to die by suicide have been to their GP in the weeks and months before that happens. So, there is a real moment of opportunity in a GP visit. That's another way of looking at it, really. And access, quick access, to therapies, to talking therapies, to information, to understanding, to whatever it is that people need, is critical, really. And looking at that through the lens of the person who's seeking help, that's the opportunity here—having that good menu, having GPs understanding what it is that they can offer, instead of feeling frustrated because someone isn't reaching a particular threshold. We hear, as we've said before, so many times about the issue about thresholds and people who fall below that threshold. But, if you look at it the other way, this is an opportunity for an early intervention, and we need to get so much better at that. So, I think there's a really big job to be done on this, but also a really big opportunity, because we have got therapies that we know work; there's increasing evidence around a lot of them. We've done a lot of work on this, but it's not properly connected and it's not resourced enough.

Thank you. So, I'm involved in a number of studies, one of which is with the Mental Health Foundation, and they all have slightly different methodologies, but what you're seeing is the same groups coming up as particularly vulnerable in terms of both their mental health and well-being, particularly with anxiety, loneliness and then suicidal thoughts. Those groups are young people, who seem to be very much disproportionately affected by the pandemic, for many reasons; those from deprived backgrounds and the unemployed; women, young women in particular; those with the care of young children; those living alone; and also those with pre-existing mental health conditions. So, consistently, across many of the studies that I'm involved in, we're seeing those.

We've also looked at—so, I work a lot in the secure anonymised information linkage databank at Swansea University, which links healthcare services across Wales, and what we see, when we look at patterns of service contact, is a real dip—and that isn't just in Wales; you're seeing it in the UK and abroad—of contacts across primary care, emergency departments and hospital departments. Potentially, that was due to a couple of reasons. So, one would have been anxiety about being in contact with services because of COVID, but also, because we did a lot of that messaging about protecting the NHS, I think that would have fed into it as well. What we don't know at the moment is the consequences of that unmet need.

And then one of the other studies that I'd like to mention that I think will have a bearing on the future is we did—. So, with the University of Bristol, we looked at Google trends data, so the sorts of searches the population were making, and there were a lot of searches about coping and what people should be doing, how to keep themselves occupied in periods of isolation. I think there's a real trick that we missed that we can do for next time, which is about suggesting to people that they both plan if they have to go into periods of isolation—so that's both as a contact, or if we go into local lockdowns—and also be very proactive about the things that we say to people about how they can occupy themselves—so, that coping and resilience-type work. And then, in terms of the changes in services, services had to transform, and mental health services, particularly those for children and adolescents.

In England, before the pandemic you were seeing about a quarter of referrals to CAMHS being rejected. So, they were services that were struggling. Now, with people who haven't been able to access services—and I think we are focusing on this—we really need to address people knowing how they access services, having pathways for people in crisis, really clear pathways, and also really strongly recommending and highlighting to people, at the earlier end of the spectrum of issues with mental health and well-being, the things that are out there where people can manage themselves, such as parental, self-directed help, peer help, and then how they access services. I think we really need to highlight those issues and address loneliness. Loneliness is another that came up in the Mental Health Foundation survey, it has come up in the young people survey—big issues strongly related to all the issues we're talking about.

That's a very, very useful overview. I know other members of the committee will want to go into various elements of what you've brought up there—access to services and resilience and what have you—in more detail. Perhaps, Dr Kousoulis, would you have anything to add, again on the general impact of the pandemic on our mental health? Were there any surprises in cohorts of the population that were more deeply affected, for example? What other reflections, perhaps, would you wish to add to that?

Yes, of course, I'm happy to add. I think Ann has a more broad perspective of different studies in Wales, and I can give a little more depth about our specific study, where Swansea University and Professor Jones's team are a key partner. Just to give you a sense, we've been collecting data since mid March—so, that's before lockdown—and we're doing repeated representative surveys across the UK, with a sample in Wales as well, obviously, roughly every month, or three to four weeks. The sample in Wales is roughly about [Inaudible.]

We've lost your sound there. I'm not sure if anything happened with your microphone at your end. Is it worth a twiddle with something? It is something to do with that plug, I think. Could you try once more? We're still not hearing you.

I can hear you fine.

Perfect. That's it, thank you.

Our study sample in Wales is about 200 people each time, so it's probably over 1,200 so far, representative of age and gender. To give you a sense of location, I have about 68 per cent living in urban areas, and about 32 per cent in rural towns and fringe. So, if we look at these data for the population in Wales since March up to early September, which is the last wave we have, we can see various emotional responses that people have, like feelings of anxiety and fear and panic, peaking around early April. At the start of lockdown, early into lockdown, anxiety, not in the clinical sense of the term but in the kind of 'feeling worried' sense of the term, was peaking at around 70 per cent of people reporting that in early April, and then slowly coming down since. So, in our latest survey it has come down to 43 per cent. Other emotions are lower—reports of other emotions like fear and panic are around the 20 per cent figure. Generally speaking, there is improvement in how people in Wales are responding and feeling in pretty much everything, I would say, except for two lines. One is around hopelessness, which has not massively and systematically improved across the whole Wales sample. So, it's been between 15-20 per cent of people reporting feeling hopeless, without any massive drop in recent months. And then loneliness: loneliness, again, peaked around May in Wales, and then dropped but has not come back to the pre-lockdown levels. 

Okay. If I could just interrupt there, is it a natural conclusion that, given how things peaked in terms of problems, mental health problems, with the tightening of restrictions, we are likely to face the same thing again as we enter another period, quite possibly, probably, of heightened restrictions again? 

Well, that's a really important question, and I think it's difficult to respond. On the one hand, we know that some people will have developed some coping mechanisms that they can use if there are similar restrictions. In fact, a lot of people are already using them in different parts of the UK. But, at the same time, we know that there is also a cumulative effect over time for some people who are exposed to that uncertainty, especially when it comes to job uncertainty, financial uncertainty. Trauma and that exposure to trauma—. We know that more people will have been exposed to trauma through losing a loved one, being hospitalised, working long hours, all of that, than back in April or March. And I think my guess would be that probably the numbers would be similar but maybe different people would experience different things, I would think. 

Okay. Professor John wanted to come in there. 

In many ways it's just to reiterate what Antonis said. I think the context has changed. So, we know that socioeconomic deprivation and employment are strongly related, and even job uncertainty, are really strongly related both to mental health and suicidal behaviours. And I think the context now—. I think there were financial supports and strong safety nets that we may not be taking into the future. So, the experience over the winter as well, where things like fuel poverty will come into play, makes the context very different this time. And the things that people can do—. In the MHF survey, one of the top things for coping was walking outdoors, and things like that will be much more limited over the winter. 

Yes, and the evenings will be darker, and so on. A quick word from you on something we've touched on already, which is the amount of data and the quality of the data we currently have in Wales. Where are we at on hard data on the impacts of the pandemic?

Who wants to go?

In Wales in particular. We know there's a wider UK study, but, in Wales, Professor John, are you happy with how much data you are able to collect now?

I would say, from my point of view, I think we're doing surveys, but lots of them are what we call 'convenient sample surveys'. So, you ask the people and the people who are interested in what you're asking tell you, but they're not representative. Then we've got these quota surveys, like the one with MHF, but the problem with those is you're trying to make it look as much like the population as possible. But they tend not to be representative of people from ethnic minorities, there tends to be a reduced—. The most deprived people tend not to get involved in those sorts of surveys. So, you can't have the answers from the people who aren't there. They're better than convenience ones, but they still have severe limitations.

I think what we haven't done in Wales, and this is even from before the pandemic, is that, in England and Northern Ireland, now, they're doing what we call 'probability sample surveys', where you know they're representative, but they're more costly and they use validated measures. So, we get the ideas about well-being, but we also get the ideas about people who are diagnosably ill. So, you get that whole spectrum, where you can direct interventions both at a population level and also at very high-risk groups. I think that's something, particularly where mental health is concerned, that is a real gap in our knowledge of what's happening. 

Let's focus, then, on high-risk groups, and, if you could, Professor John, provide us an update on the work that you're doing to understand the impact of the pandemic, specifically on suicide and self-harm in Wales, and talk to us about the data that we have and the additional data that we need in order to understand the situation better. 

So, where suicide and self-harm are concerned, particularly for suicide, the way we count deaths by suicide is following a coroner's inquest, so there are always delays in registration. Now, what that means is that when the Office for National Statistics produce their bulletins, which is the very reliable data that we have, it's usually a year out of date, which means we can't respond in real time. So, I think it's really important to set up a real-time suicide surveillance system. It would be about suspected suicides, which means that we can get bereavement support to people in a timely manner, but also know what's happening and who the high-risk groups are.

So, Welsh Government have set up a task and finish group, and I think this is something that, in Wales, because of our size, we can do really well on. What that would mean is that we can be much more directive in our interventions. So, addressing suicide prevention is really a public health issue, where only a quarter of those who die by suicide are known to mental health services. That broad approach needs to be complemented by addressing high-risk groups, of which—. So, young people come up here again. Although suicide is, thankfully, rare in young people, it has been increasing since about 2010 in the UK, and that's alongside increases in anxiety and depression.

So, I guess the concern is that those trends will be exacerbated and entrenched in the current situation, but at the moment—and we're not the only place—we don't know what the figures are. We've tried to look in the SAIL databank, but I can see from my knowledge of numbers that we're not able to see all the deaths. There is some evidence from abroad that there may have been a slight drop early on, but we really don't know. But the relationship between suicide and deprivation and unemployment is so strong and well known that I think those sorts of financial welfare wider determinants—housing, fuel—are really important, going forward. 

Yes. Dr Kousoulis. 

I would just add an interesting statistic from our study that supports what Ann is saying, which is around how many people from Wales said that they would be willing to contact a mental health worker or professional, or a counsellor, to help them cope with the stress of the pandemic and that hopelessness. And it's only between 1 per cent and 2 per cent across the Wales sample, and, in fact, a bit smaller than the numbers reporting that in England, Scotland and Northern Ireland. Potentially, we can have a discussion about why this number is so small. We have done in the past and worked with Public Health Wales, for example, on farming communities. We know that, amongst farming communities, which are quite substantial in Wales, there is a lot of stigma, people not reaching out to professionals. I think I'd agree on that point that suicide prevention is not only an issue for mental health services—there are a lot of people that are not known, or certainly not reaching out, to mental health services. 

I'll leave it there for now, Chair. Thank you, both. 

Moving on then, Lynne Neagle. 

Thanks, Chair. Before I go on to my questions, can I just pick up where Rhun left off and ask you what I asked the previous panel, which was to flag that there was a new Minister for mental health and well-being announced last week? Their responsibilities were circulated to Members of the Senedd last night and the word 'suicide' doesn't feature at all in the list. I'd like to get your response to that, please.

So, while I completely welcome a Minister for mental health and well-being—I think that's brilliant—I really strongly feel that having suicide prevention specifically mentioned in the Minister's portfolio, because it's so much broader than mental health—the stigma and care pathways are different to those in mental health—. The broader public health approach, while there are huge crossovers, is particularly important to suicide prevention. So, I would really welcome, and strongly support, suicide prevention being mentioned specifically in the Minister's portfolio, as it is in other nations. 

Thank you.

Dr Kousoulis.

I 100 per cent agree, and second the point that Ann has made, yes.

Great. Lynne.

Okay, thank you. Just turning, then, to specifically at-risk groups. How do we strike the right balance, then, between targeted interventions at those who are highest risk and preventative action at the whole population level?

Who wants to kick off? Dr Kousoulis. 

Yes, I'm happy to kick off. There is a framework already in public health that we have for this kind of question, which is a great question. We call it—it's a bit of jargon—we call it 'proportionate universalism', and it kind of says that we need a number of different interventions to address population health issues. And the scale of resource and intensity that we would deploy to this intervention should be proportionate to the level of risk, essentially. So, if you look at the proportionate universalism, it's often represented as a pyramid. At the top are universal interventions, and then we go towards the middle, which are the more targeted ones for those who are at higher risk, and then at the bottom are the ones for those who are experiencing more severe problems.

So, if I simplify that, we need a little bit for everyone. So, we need those anti-stigma campaigns, we need to encourage people to reach out, we need those kinds of connections and community-building across the whole nation. But then we need a little bit more, if you like, on supporting those whose needs are increased, and who are more vulnerable, for whatever reason. And I think this is where some of our approaches around targeting and addressing discrimination, people who are very lonely and socially isolated— . And then people with pre-existing health conditions would fall into the next category—those who require an ongoing, extra layer of support, especially as we've seen those vulnerabilities expressed in pretty much survey after survey in the past few months. 

Professor John.

I completely agree with Antonis there. I think the other ways of looking at it is to think about the life course. So, very much think about adverse childhood experiences and parenting and environment, and then accessing support, very much investing in the young, but making sure those with existing problems aren't left behind. I think that addressing wider determinants, so all the things I listed before, is very much about this sort of taking on a population approach, but then thinking about those who are at risk. 

And then I think in the current situation, services virtually have had to transform overnight, and are delivering care in very different ways now. There's lots more telehealth, whether it be phone or video consultations. Some of that transformation happened before the real evidence existed about how effective and how well it works. And I think we have to really strongly push for ensuring that those services are evaluated, particularly with a view to how high-risk populations are engaging with them. Some may prefer it, because you don't have to travel, it's less intrusive, it's less face to face, but others may not engage with it. The way forward may be a blended approach, so that we're offering very different types of services that people can access as and when they need them. So, particularly for young people, sometimes there's a real need for face-to-face contact, and sometimes contact—you know, either online services or services over video are available. But I think what we need in that sort of really transformed landscape are clear pathways that people understand.

Okay, thank you. Can I just turn to children and young people, then? There's been a very clear message today about the vulnerability of young people. Our previous panel told us that it was paramount to keep schools open for children and young people's mental health. Today, now, we've heard that Northern Ireland are having a circuit breaker of four weeks, where schools will be closed; we understand the First Minister is looking at a circuit breaker for Wales. How concerned would you be if schools would have to close in Wales again, in terms of young people's mental health?

Professor John.

I think these are difficult decisions. You're very much balancing protection and the physical aspects of COVID-19 with the indirect harms that happen as a result of isolation. The way I look at it is that it should almost be a last resort—so the last thing we should be closing down is schools. I think it may be necessary, within the wider context of the pandemic, but it should be the last thing—it should be after pubs, after other measures that we can take to curb the spread of the pandemic. And I think we need to be really proactive, if it does happen, in how we engage young people. Because as we all know from last time, schools for many young people are the safe place, where their peers are, where their trusted adults are. For all children and young people—. Their brains are different to ours—biologically, there are all sorts of things going on, and they are much more—. We all know this anecdotally, but peers are paramount to them, so losing those supports is a huge issue for young people, and it came across in all the loneliness surveys. But for vulnerable young people, home may also be a place that they're not safe. They may be witnessing domestic violence, there may be lots of family conflict, and lots of young people will be experiencing complicated bereavement with separation. So, as far as I'm concerned, closing schools should be the last resort.

Thank you.

Okay. Dr Kousoulis.

Yes, 100 per cent agree. If you look into research around mental health across decades, in different nations, education is such an important protective factor for mental health. And we tend to forget it, because every child here goes to school and things like that. But as Ann says, we need to shift the conversation, not from whether we be closing schools, but what the supports are that we need to provide families and key workers so that we can keep schools open as much as we can. Of course, as a last resort, this is a decision for public health infection specialists. But I agree with Ann, schools are such an important part of young people's identity, and socialising and community, that we're taking away a lot of protective factors for their well-being if we're closing schools.

Okay, thank you. Can I ask about self-harm, then? Do you think that sufficient priority is being given to self-harm as an indicator of suicide risk and to improving support for those who self-harm?

Professor John.

Prior to the pandemic—. I think there's a lot more we can do. It's really important to realise that many, many people—most people who self-harm do not seek help from services. Three adolescents in a class of 30 will be self-harming, and so there's work to do about raising awareness with parents and people who work with young people to respond. It's very stigmatised—self-harm—for young people. It's very private behaviour; people are very ashamed. I think one of the things, though, in the work that we've done looking at services is that there was a sharp drop in contact with self-harm across primary care, secondary care and emergency departments. And it's important to highlight that primary care is a really important source of contact and support and accessing broader services in self-harm. I think we focus a lot on emergency departments, but, actually, more people contact their GP. I think that drop probably reflects an issue of access and the things we talked about first rather than any real change in community prevalence.

So, studies from around the world and surveys have shown, particularly in young people where self-harm is much more common, that there were increases particularly in the early part of lockdown. We don't know enough, because the data we have is about services. And I guess the concern is that a lot of people who might have sought help haven't, and what's happening to them? And I guess what that means is that we need to have really clear signposted sources of help and support online and in the community and we have to have clear pathways for those in crisis, of all ages.

Dr Kousoulis on self-harm.

I find, again, I agree—I mean, Ann and I work together and we tend to agree a lot anyway. I think it's interesting that I find, in our surveys, a lot more people report suicidal thoughts than self-harm, and that may well be very true, but there are potentially some issues around stigma—around people reporting having self-harmed or not, and obviously it's much more pronounced, as Ann said, in young people.

Potentially, I would like to bring into this conversation, which is a slightly different definition, those unhealthy ways of coping, as we sometimes say—people drinking too much and smoking more and using illicit drugs. We do have some data from our study on Wales, where we see that, consistently, I think, with other places—with the other three nations in the UK—eating too much is one of those unhealthy ways of coping; drinking more alcohol, even though it has been decreasing in the past couple of months; and about 1 per cent is using more illicit drugs than it did before. And 1 per cent sounds small, but it's potentially some thousands of people in Wales. So, I think bringing that kind of conversation in there might help make it a little bit more real for services, potentially, as well.

Lynne.

Thank you. This committee, as you know, has been very keen to see parity between mental and physical health. What do you think the challenges are, especially in the context of a physical health pandemic, to actually delivering that parity that we want to see and that Welsh Government claims it wants to see?

Ann.

So, in many ways, you hit the nail on the head in the way you phrased it. I think, in the face of a viral pandemic, there is a real natural focus on the physical consequences and the consequences for physical health services and intensive care and managing symptoms. I think there is a recognition that there are mental health consequences and other indirect harms, such as alcohol and domestic violence, and how all those impact on mental health and suicide and self-harm. I think we have to continuously lobby and I think that's reflected across the board.

So, mental health services and research have been chronically underfunded and I guess my concern is that that will be exacerbated in the light of the focus on the pandemic. I think it's up to all of us to make sure that that stays at the forefront. When you're taking certain measures like school closures that has huge impacts in terms of not just current well-being, but long-term future trajectories. So, as Antonis said, there's the protective effect of education, but there's also loneliness. There are studies that show its impacts on mental health 10 years later, and what we want to avoid is what we call a cohort effect, where there's a particular insult dealt to a generation and those vulnerabilities follow them through in the long term. So, it really is about leveraging protections and services and access to care. 

Dr Kousoulis. 

Again, I agree. This is so important. I think if we—. We have to—. In many ways, we want to look at data and work with these numbers, but, in many ways, we're going to have to understand that there are people behind those numbers, and when we talk about—. We've seen in our study with Ann about 10 per cent of people reporting suicidal thoughts quite consistently since April. Ten per cent—that's thousands of people waking up every day with thoughts that their life is not worth living, and it's quite a difficult way to live your life. So, I don't think we can—. Of course, there is—you know, the measures around restraining and containing the infection and how the virus is transmitted are important and they do take priority, but we cannot lose sight of those mental health impacts. And we're actually in a little bit of an advantageous position, because we do have some research from previous pandemics now, and there will be a next pandemic, and they will have even better research from all this stuff that we are doing now, but we're not doing this for the next pandemic; we're doing it to ensure that the focus is maintained right now. 

Thank you, both. 

Okay, Lynne. Moving on, then. Jayne Bryant. 

Thank you, Chair, and good morning. Just moving on to some questions around resilience, and you touched on this at the start in answers to questions from Rhun, but how do we avoid over-medicalising mental ill health while ensuring that appropriate support is there for those who need it? 

Professor John.

So, I think part of it is about being careful about our language and public health messaging. So, I think the promotion of resilience is about thinking for people about coping, planning and adjusting—to normalise for people that, in terms of uncertainty, it's difficult. It's about having measures that protect them from those wider determinants—so, welfare safety nets, thinking about poverty, thinking about access to food. So, there are those protective measures, there's supporting people in how they cope, and by that—. I think that works equally for the general population, who may be anxious but not in a medicalised way—we're in a pandemic; it's okay to be fearful. And those coping strategies are the things that you can do. In the Google trends study, people were looking at all sorts of—you know, where to go walking, how to cook this, hobbies. It's giving them those messages, and then also public health campaigns that potentially give people pointers on how to do those things and how to cope and what to do.

I think an important thing here is what we call co-production. So, I think we're at a stage where we're coming into winter, we have time still to really co-produce resources and coping strategies with people, because those are going to be different things to different people, depending on their context of access. And I think for some of the more high-risk groups that we talked about—and I don't necessarily mean high risk for mental health or mental disorder, I think just high risk for life being really difficult at this time—we need to be providing for them. Lots of community groups happened at the beginning of the pandemic—people were collecting prescriptions for each other. Some of that has waned as people have gone back to work and their daily lives, and I think we need to make the most of those sorts of community groups.

Excellent. Dr Kousoulis.

I guess it's one of the positive things of the pandemic, potentially, that probably more of us understand why our mental health is impacted by what's happening. Our historical approach to mental illness, as you say, is very medicalised. But we are now understanding, 'I am lonely. I fear that I will lose my job. I won't have food for my kids' and things like that, so I think these are very real concerns and stresses that help us maybe shift the conversation a little bit to those real struggles that people have in their daily lives and a little bit away from necessarily making everything a diagnosis. So, coping is really important—how are people coping and what kind of ways they're finding to cope. And I think if people find ways that help them, as we have seen in those surveys and studies that they do—like walking and going out in nature and connecting with friends remotely and things like that—then they can also start feeling more confident about that self-care aspect, the self-management aspect.

In fact, the numbers in Wales seem to be a little bit better than in the other three nations. I'm not 100 per cent sure of the significance so far, but they are a little bit better, in terms of how people are coping, compared to England, Scotland and Northern Ireland, how hopeful they feel, and they're feeling a little bit less anxious. And in one of those focus groups we are running, there was somebody in it from Wales who said—. We asked, 'Do you think this is a real finding—that people in Wales are coping a little bit better?' And they said, 'I think that we have this getting-things-done attitude in Wales a little bit more', which I thought was a beautiful and positive thing to say.  

Ann John.

I just wanted to add to that that that sort of collective responsibility and that social cohesion—that works both for mental health, but also in combating the pandemic. So, I think a huge way to address both things is to be really careful about our discourse as a nation, to not be 'othering' people—it's this group, it’s that group, who are being good or bad—and really be collective in our responses, and I think that works for both sides. I think it works both for COVID and the protective behaviours for that, but also the protective behaviours for mental health and distress.

Excellent. Jayne.

I think you're exactly right, and I think one of the issues, perhaps, in the initial lockdown, was that some people who'd felt isolated and lonely before, actually, were saying well, for them, things hadn't really changed. But for a huge amount of people who used coping mechanisms such as friends or family, who they were able to see easier—that came as a bit of shock to so many people. And I think the attitudes of people going into different local restrictions can—it sends a bit of a fear into them of how long this goes on for and worries about how they're feeling. I just wondered—you touched on things like coping mechanisms in terms of being able to be out and about, but have you seen any recent trends from the local restrictions and people feeling, 'Right; this might go on for a long time'?

Dr Kousoulis, do you want to kick off on that one?

Sure. I think people have been watching the responses change over time, depending on the context, and there are a few—. When we look at these local lockdowns, there are a few factors that influence how people are feeling and responding. People are tired, people want to get back to normal—whatever that is—and people may have experienced trauma, fearing for a job. So, I think that local lockdowns or local more intensive measures should really be accompanied by protections for people's well-being, because responses might be a little bit more—a lot of disappointment, maybe anger. There are global events happening impacting people. There are things like what's happening in the other nations, the American election, Black Lives Matter. There are all sorts of global events that are also influencing how we're feeling and how different communities are feeling, and we should be taking those into account in terms of in what ways people are impacted.

Professor John.

So, there's a thing called COM-B in behavioural research, which talks about when you're trying—. When you're thinking about measures that you're trying to put in place, you've got to think about people's opportunities to do them, their motivation to do them, and their capability to do them. And I really think the way we need to look at this is to enable people's choices. So, some of the things that will be difficult for people going forward, when they're thinking about what happened before, will be job opportunities, retraining. For young people, lots of them work in the hospitality sector. So, in some ways, I think that uncertainty of what's happening and all the mixed messaging is very challenging for people. And there are things we can do to address that. Both in the NHS survey and other surveys, people are concerned about their prospects and the future, and we're all talking about recessions and job opportunities, and that is what people are experiencing on the ground. And, potentially, interventions that give them safety nets but also offer—. I'm not talking about ballet dancers in posters here, but offering genuine opportunities for education, training or retraining or employment that we can guarantee for people in some ways. I think there are ways that we can be really proactive about the scaffolds that stop people's fears and uncertainties that are uncomfortable to live with.

Okay, Jayne?

Thank you, Chair.

Well done. Moving on, as time is marching on, naturally, David Rees.

Diolch, Chair. Good morning, both. You've talked this morning in some of your answers very much about the parity between mental health and physical health and the importance of making sure we have the right measures in place. I know that, back in 2016, the Mental Health Foundation produced a report that looked at a public health approach to mental health. Do you think the pandemic has brought us any closer to that or are we still far away from it?

Dr Kousoulis.

I'm struggling with this one. I think in some ways it has, and then in some ways it is challenged. I think there is a little bit of a global move towards threatening public health thinking, and I think the risk with the pandemic is that—. Let's say this: our legacy in public health—for those of us who are public health professionals, our legacy in public health is one where public health equals 'let's protect against infectious diseases', and it took decades to get to this point of thinking about public mental health, public health as prevention across the whole of society, thinking about public health in terms of policies and measures and strategies and central Governments and devolved administrations and things like that and local communities, and now a lot of the interest again is shifting towards control of infectious diseases. So, that's a very real risk of reversing years of progress and understanding and training.

At the same time, these past few decades have also brought new generations of people being trained to do that thinking. So, it's not going away. These conversations about public mental health, just having these inquiries into mental health and the pandemic, those studies, they're also reassuring that this is not going away. And so, we will have to keep pushing, we will have to keep working, I think. It's not a journey that I think stops with the pandemic, and I think there are opportunities and there are risks. I don't have a clear answer at the moment as to where things will be in one or two years, but I know that there are many dedicated people and organisations that will keep working on this and public health thinking across the board, not just in terms of control of infectious diseases.

Professor John.

I do agree with Antonis; I think there has been a movement in the conversation. If you think about public health as about prevention, as about looking at the life course, as about advocacy for those who are more vulnerable, or in socioeconomic adversity, and the wider determinants—so, I think we're all having those conversations, and that's great. I think one of the things that the pandemic has done is, you know, people talk about public health a lot, but associate it with infection. Everyone knows what an epidemiologist is now, whereas before, they really didn't. But, to make those real changes and to have that real parity of esteem requires resource. That requires hard commitment, not just talking, and you need to see that across research, services, systems. I'm not convinced yet that we're there with that. I think it's better than it was, say, 10 years ago. We've recognised the vulnerabilities of, say, healthcare workers—we haven't talked about them in this session—and there has been a nationwide PTSD system set up. But in some ways, it's piecemeal services. I think there has to be a real recognition of those wider determinants, and how addressing those addresses physical and mental health equally. The mortality impacts of mental health issues are equivalent.

We didn't have a question on the mental health situation for care workers in particular, but since you've raised it, I'm more than happy to ask the question as to your views as to whether the actions that have been taken really reflect the need to address the mental health issues for care workers and NHS workers during this pandemic. If we'd had a proper public health approach to mental health, would we be in a better position for those staff?

Professor John.

I think with the pandemic and the situation that health and social care staff across the board were in, there's the issue of moral injury. So, the choices that they had to make, whether they felt safe or not—I think those issues are bound to have affected their mental health. I think the recognition that it has is a real step forward. I was a GP and worked in an emergency department in a previous life and I don't think then there was very much recognition, so I think that's a real step forward, but there's a pressure between delivering a service—so, when you're acknowledging people's mental health issues and they maybe take time off work, there's a whole raft of people who have to pick that work up. So, ultimately in many ways, it comes back to the argument about welfare and employment safety nets for people. We need adequate staffing in order to protect people's mental health. They need to feel safe, they need adequate PPE, and then for those who are still experiencing mental health issues, we need to ensure—. There's a lot of stigma for people in health and social care. They're meant to be the sorters and the problem solvers. It's very difficult for them to seek help. So, we need to make sure that they know where to do it in the different ways that they want to do it. So, you know, many don't want to go—. Say, for a GP, they'll know every other GP around them, so they're not going to want to access services in the same way that others do. I feel, personally, that key workers—not just health and social care workers, but key workers—bore a lot of the brunt of the pandemic, and it's a responsibility of ours to make sure that they're supported going forward, because many of them are having to pick themselves up to do it again, potentially. 

The First Minister has just announced a slight reshuffle of his Cabinet, and identified a Minister for mental health now to take on the work on mental health areas, and to allow the Minister for Health and Social Services to focus on the pandemic and NHS delivery and performance. Do you see that, in the long term, as the future direction we should be going in? What are your concerns in relation to the resources and the funding that might be allocated to that area?

Shall I go first?

Yes.

I think this is an age-old problem that we suffer across the board. Is it better to separate physical and mental health, so that you can advocate and make the case? Or is it better that they have parity of esteem and are integrated? Now, I think, in terms of having a Minister with a specific responsibility, I really welcome it. I think, in the current situation, there is, understandably, a complete focus on managing the pandemic, so having someone who is specifically looking to those indirect harms and mental health is a strong way forward. So long as there is parity—I think parity is the important thing; whether you do that by integrating or do that by advocating is different. I have spent my career going, 'What about mental health and well-being?'

Dr Kousoulis.

I agree with Ann. I think it's important to remember that a very small proportion of overall health service funding goes to mental health services, and an even smaller proportion of overall public health funding goes to public mental health. And I think, as we go on, it's really great—I agree, I really welcome a Minister for mental health, but it will also take some political will when it comes to budget setting and spending reviews in terms of where money is coming from and where it is allocated, and using evidence to do that. We need better services for mental health, absolutely, but they won't do, they won't be enough. We already had big demand for mental health services—and need—before the pandemic, so we do need to understand public mental health and the position of prevention and interventions in the community, and empowering communities and grass-roots organisations to support people around them that they have an intimate knowledge of. So, I think this is a really good first sign, and I think Wales has, in many ways, led with a Well-being of Future Generations (Wales) Act 2015 and things like that, which are examples that we use in other settings, and we encourage England and others to do something similar. But I'm afraid that this kind of need for political will and better and more clever funding allocation is still going on; we still need to see more action there.

And I think that sort of funding allocation is across all levels. So, it's political in spending reviews, it's for services across the board, both at population and high-risk groups, but it's also for research. So, where Antonis mentioned evidence, you need to be funding studies to know what that evidence is, and the funding for mental health research compared to physical health research—it's been chronically underfunded for decades. MQ did a report last year on that, and even I was surprised at the disparity. And then, when you look at that, the disparity for child and adolescent mental health research is even broader. So, I think we've maybe made big steps in talking about it and highlighting it. I think it really is making sure that it's all adequately and equivalently funded.

It's important to make sure that the ideas that are being put forward actually are resourced properly to ensure that they're delivered. The final question from me, in that case: is there anywhere we could learn examples from as to where that type of approach is actually working and is beneficial? I suppose it's part of the research you're talking about—to understand other examples.

Dr Kousoulis.

There are some examples, especially when we think about the pandemic in a holistic way and the associated recession measures and people struggling in the years to come. We need to start reconsidering a little bit how we allocate resources and how we choose to measure success as a nation more widely. I think there are discussions about a well-being economy, which places like New Zealand have done, and that could be a step towards that direction. I think whole cross-Government plans to improve our focus on mental health across different areas—just in the past hour we've talked about education, we've talked about communities, jobs and pensions and all of that, and unemployment. So, these are some of the directions, and I think there are examples from other nations and other countries of the world, and also examples of some good papers as well. We're happy to share some of that with the committee as well.

Thank you. Professor John.

Internationally, there are lots of studies looking at the relationships between large inequalities in income and mortality, and also looking at unemployment and suicide. Suicide rates tend to rise—so this is outside a pandemic situation—slightly before unemployment rates rise, because of job uncertainty. If you look at a nation level at countries that have smaller inequalities in wealth between sectors of society, but also have active labour market policies—those things are protective. So, there are broad social measures that you can take for which there is reasonably strong evidence that they work.

There are studies out there—preventing bullying in schools has a strong impact on mental health. There are programmes like the SAIL programme that they've trialled in European countries that we know have had an impact on self-harm and suicidal behaviours in young children. It's about making that evidence base happen. So, I think, while I'm saying we need more funding for research, we also need to plug that gap where the research that exists is actually operating in our populations. Sometimes, what happens is you might have strong evidence for an intervention, but by the time it's filtered down to being delivered, it bears very little resemblance to the original intervention. So, I think there's evidence out there for things that we know we can implement and that work.

Thank you.

Great. We've come to the last section now and questions to wrap up from Andrew R.T. Davies. Andrew.

Thank you, Dai. Thank you, witnesses, for your evidence so far, you've given us a lot of food for thought. Really, my question is a catch-all question, which you covered partly in your last response to David Rees. But given the work that you specialise in, what examples or what thoughts can you leave with the committee that would help inform and base recommendations to Government on, given that, obviously, the committee's undertaking this review?

There you are, there's a power base for you—suggested recommendations for Government action. Professor John, you're good at that.

I guess the important point is that the impacts on population and individual mental health, and also suicide and self-harm prevention, are not inevitable if we take action to mitigate those risks. So, even if we don't know what's happening, taking that action—. I think those are the things—offering opportunities to people, particularly young people in terms of education, employment and training. I think it's about ensuring that we have strong welfare safety nets for people. I think going into the winter we need to be looking particularly at fuel poverty. It's horrible to have to say it, but we need to be making sure that people don't go hungry. We can be giving advice in terms of the pandemic, about how to cope, and ensuring that we promote social cohesion as opposed to division. I think the evidence is out there. I think we know what a lot of the risk factors are, and we should be addressing them. So, if we're thinking about closing schools, we should have things in place to ensure that young people's social networks continue, but not in—. There's lots of evidence that it was very unsupervised, and so there may have been increases in things like cyber bullying. So, having much more active connection and involvement—that we are proactive and plan, I think.

Could I just ask, on the schools point that you made, we are all rightly focused on schools, but obviously FE colleges, for example, and universities are homes for many young people, so would you treat FE colleges and universities in the same bracket as schools when you say that they should be the last to shut, if indeed they should shut at all?

That's a very complicated question. So, in the work that I normally do, I would think of young people aged up to 24. That's when they're going through massive transitions in their lives that can make them vulnerable. They haven't learnt coping and resilience strategies, and their brains are different. However, I think I would look at schools and FE colleges in much the same way. I don't think we can treat FE colleges differently to how we can treat sixth forms attached to schools. I think universities are different, and the reason they're different is because, particularly for first years, they've been moved away from their usual social supports. So, I think we do have to treat universities very differently, and we need to really make sure that young people who've been taken away from their usual supports are really supported. I know there's lots of work going on in our universities to do that, but I think we need to be really careful as a society that we don't 'other' university students.

Dr Kousoulis.

I can give a brief and additional perspective. I think some of the key actions that will be important are to not undermine the non-infection control public health functions. I think that will be really important for Wales. Trauma-informed care services will be fundamental in the next few months, as ever, but even more so in the next few years, not just in the NHS, but more broadly in education, criminal justice, blue-light services, across the board. There's improving the infrastructure to enable social connectedness, especially for the next few months. I would prioritise local authorities and local community organisations that have that understanding of the needs of local populations, and I think it's also important to empower communities that are at risk for whatever reason. We need to empower ethnic minority communities to produce solutions or the messaging—that is important, and for them to help each other. Farming communities as well, and fishing communities in Wales—we've already done work with Public Health Wales and there are recommendations there just to produce some new plans, in already a time of uncertainty because of Brexit, but just to produce, you know, what the future could look like, what the financial—where would it come from, and how we can decrease stigma for seeking help in some of those populations.

Excellent. Thank you very much indeed.

An excellent session—bang on time as well, so very efficient.