Cynulliad Cenedlaethol Cymru

Bore da. Good morning, welcome to the Health and Social Care Committee this morning. I move to item 1: we have apologies from Sarah Murphy this morning, and if there are any declarations of interest, please do say now. No.

In that case, we'll move on to our next item. Just reminding you that this is a bilingual session as well and we have some witnesses joining us this morning virtually and some here on the Senedd estate. So, as I move to item 2, this is in regard to a series of sessions gathering information for our inquiry into supporting people who are living with chronic conditions. I'd like to welcome the three witnesses with us today and ask them if they could just briefly introduce themselves for the public record. Oliver.

Bore da. Good morning, everyone. Ollie John, I'm the chair of the royal college mental health expert advisory group.

Lovely, thank you. And if I come to Andy first, perhaps.

Hi, everyone. I'm Andy Bell, I'm chief executive of the Centre for Mental Health. We're a UK-wide charity dedicated to tackling inequalities in mental health.

And James.

Professor James Walters. I'm an academic psychiatrist and consultant psychiatrist in Cardiff University, and work with Ollie in the royal college as well. Thanks.

Lovely. Thank you all for being with us this morning. I appreciate your time. So, perhaps if I ask, perhaps, a wide question to start with: how do we ensure services that are person centred for those with chronic conditions and how do we make sure that care is appropriate for those who develop mental health conditions as well in that setting, if you like? Perhaps, Ollie, I'll come to you first. Ollie John.

Absolutely, I think the very nature of mental health means that we should be better at person-centred care than, perhaps, anyone. There's a suite of things we could list around what's important to people in terms of shared decision making, empathy and various other really important things around patient-centred care. A couple of things that I probably would highlight that I think it's worth the committee discussing and understanding are around things like advance choice. So, regardless of where you sit in mental health conditions, whether they're mild-to-moderate, or whether you are subject to things like mental health detention under the Act, you should have a say in how your treatment is. So, things like advance choice are things that have come out of the Mental Health Act 1983 review and discussion, and these put in place things for people who may be detained again to know what care they should and wish to receive. So, mental health really should be shifting to a rights-based approach that looks at principles around things like choice and autonomy and how people wish to receive care.

And just thinking about that—. Thank you for that, Ollie. I suppose you've set out there what should be the case, and perhaps expand on why that is not the case—those blockages to what you think, perhaps, should be happening. So, what needs to happen to remove those blockages?

Yes. A lot of this is based in strategy and in legislation. We have very little mental health legislation, but, if you look at the mental health Act, it's not been reviewed since—. Well, it's been reviewed, but it's not been developed since 1983, so these are significant periods of time, and things have moved on since then.

Should it be?

Yes, absolutely. And there have been reviews into the Act; there's a Bill passing through the Senedd at the moment, getting scrutiny, and there's a lot of merit in that around fundamental principles of choice and autonomy, the least restriction and therapeutic benefit as well, and this very much puts the focus upon patients having a say in how they wish to receive treatment. Obviously, I've mentioned the mental health Act, but the principles are relevant regardless of which touch point within mental health you may access.

Sure. Thank you, Ollie. Perhaps, Andy Bell, did you want to come in on any of those two questions at all as well?

Yes, thank you. Looking particularly at the kind of interface between mental and physical health, we know—and I know the committee has heard—that people living with physical health conditions have a far greater risk of mental health difficulties or poor mental health and the more long-term conditions you've got, the greater that risk is. We also know that people living with a long-term mental illness have far poorer physical health. So, when we're talking about person-centred care, it's really important that we're talking about services that are properly holistic that support physical health for people with mental health difficulties and emotional well-being for people with long-term physical problems, and that both understand that health is socially and economically constructed. So, it's things like being offered support with money, with housing, relationships, debt, work—all these things are incredibly important—support with education for children living with long-term physical or mental health difficulties. And person-centred care, really, is simply about realising that the individual is the expert in what they need and providing a range of support around people. And what we tend to find is that there isn't a one-size-fits-all solution; there isn't going to be one intervention that helps everybody all the time. And one of the benefits of having approaches where you use co-production and co-design is that you can actually build services with the people who are living with mental or physical health needs in ways that work for them.

Thank you, Andy Bell. And Professor Walters, I think you wanted to come in, but if I could also, perhaps, ask you if you've got any examples that you think you can share where people living with chronic conditions have received good support in terms of their mental health. 

Sure. It's worth reiterating, I think—the panel are probably aware—for those with severe mental illness, which is, for secondary care mental health services, the bread and butter of what those services provide and the people they support, then people in that group have a life expectancy of 20 to 25 years less than the population. So, that's the stark finding that we're up against here. Now, the vast majority of that decreased life expectancy is attributable to physical health causes, not direct causes of the mental illness itself—and it's cardiovascular and respiratory disease and the kind of multimorbid states that the committee will, no doubt, have been considering more widely as chronic health conditions.

What we know is that we need to monitor those things, and that's not done well, to be honest. The national audit of psychosis and schizophrenia tells us that that's improved in recent years, but it's still not done as well as it should be within mental health services. So, being able to monitor people's weight, their cardiovascular function, is a really crucial element to addressing this issue.  

What needs to change to make that happen?

I think that we should make it an expectation of clinicians that there is an annual review. This used to exist in primary care for everyone with severe mental illness, but I think it should be done within mental health services. There's the capability there to do that. There's nurse training. Early intervention services for psychosis, which the Welsh Government has invested in, are really well placed to do this and have done it off their own backs, to an extent.

Why is it not being done, do you think?

I think it's pressure on time and caseloads, and the fact that services are firefighting rather than doing preventative work in this regard. The other reason it's imperative is because the drugs that we give people are associated with weight gain and increased rates of diabetes. So, whilst they're very effective drugs for psychiatric issues, they do come with this array of adverse effects. As clinicians, it's balancing those two that is important. So, it's beholden upon us to monitor these things, actually, but it's not done as much as it should be for those with severe mental illness. 

To come on to your point about good examples, I think that one I can give—. One way in which we've tried to address this—and we've been supported by the Welsh Government and Genomics Partnership Wales to set up this service—is to set up the all-Wales psychiatric genomics service. We come from a position of doing a lot of research into the genetics of these conditions, and we know that there are quite rare but important genetic risk factors for developing schizophrenia and other neurodevelopmental conditions, for instance. So, we set up this service to be able to identify people who may have these genetic variations. The justification for that, really, wasn't that—. Because the people that we are seeing have already got psychiatric problems, but these genetic risk factors are also associated with a whole host of physical risk factors. Those range from kidney disease to thyroid disease to cardiovascular disease—so, the kinds of chronic conditions that the committee is considering.

So, this service has now been under way for the last couple of years. We've had renewed and expanded funding this year. I think that the people we've seen in that service, and their families, have reported that it has been helpful. It's led to targeted screening—for instance, echocardiography to pick up structural heart defects that otherwise wouldn't have been done. Now, that's a small example, and it's not going to change the situation that I laid out at the start of my response, but, with various of these initiatives, will begin to eat away.

The other thing I'd say is that smoking is a big, big contribution to that decreased life expectancy. So, if we can do directed and personalised things about that, it would be good. And the second is making available physical activity and interventions that can improve people's physical activity across the board, but also for those, particularly, with severe mental illness. 

Thank you. I know that there are quite a few questions that Members have to dig into some of what you've just outlined there, Professor Walters, so thank you for that. Jack Sargeant.

Diolch, Cadeirydd. Can I open this up to all of the panel? Do you think that the Welsh Government’s draft mental health and well-being strategy sufficiently addresses the needs of people living with chronic conditions, and, if not, what's the strategy missing? Who wants to go first? Shall we go to Ollie? 

There we are. Ollie.

Yes, absolutely. I think it's really timely, this inquiry. The strategy is currently out for consultation. The independent review of 'Together for Mental Health', which was the previous plan over 10 years, did highlight that both chronic conditions and severe mental illness weren't present in the strategy as they should have been. That's quite sobering to read, when you consider that that's a 10-year strategy. So, we do have to redouble efforts to make sure that this new strategy—. It's really imperative that it's in there. And I think what is encouraging is that there is an approach with this new strategy around cross-governmental work. I think a greater recognition of physical health impacts as well, associations with poverty, socioeconomic inputs—all those sorts of things. We have the opportunity to get it right, but it is a reflection that, previously in strategy, SMI and chronic conditions haven't been present, so it's really important that it is. When we come on to recommendations from this session, I think there are a few that I'd like to put forward around how we can start to hold Government to account to that strategy.

Okay, thanks. I think we'll come on to recommendations later, but would it be a fair assessment to say, then, that the current strategy does have recognition from the Government and the Government should be looking for organisations like yourselves who will respond to the consultation and take those seriously?

Yes, absolutely. The draft strategy that has come out does have a stronger recognition off the back of the independent review for chronic conditions for SMI. I think one of the—. Sorry, when I say 'SMI', it's severe and enduring mental illness. I think one of the challenges is around the infrastructure in the system, because, as James alluded to, it's an area that still, understandably, needs an awful lot of research around those interventions, and so we're not going to know right now what we're going to need for the next 10 years, but we need to build an infrastructure where we can keep developing services.

Again, I'm trying to get in my head the picture of where we are. So, we're moving in the right direction, but we need the action to follow it up.

I think so. I think the recognition is there in this strategy, which is good, but, as with anything, it's what that implementation plan will look like.

Thanks, Ollie. I'll move on. If I can pick up on some of the comments from Andy in response to the Chair earlier, I think in one of your responses, Andy, you said that there needs to be a properly holistic approach to supporting people with chronic conditions, both physical and mental health. Can you just explain to the committee what the role of a mental health professional should be within the multidisciplinary team, and what would a properly holistic approach look like, and does that happen now?

Thank you. I think we see it very rarely now, and I think we understand that there are huge pressures on both mental health services and what we call physical health services, long-term condition services. So, they're working in resource-poor environments. They're working in stressful environments. They're working in environments where you don't have time to talk to people. You don't have time to build relationships, very often. And I think what we know is that good, holistic support where you have got what we've described in a piece of work looking at specifically support for people who have chronic kidney disease that we need psychologically informed kidney care and kidney-informed psychological care—. So, what that means is that your workforce in long-term condition services in physical health has at least a basic understanding of people's mental health and how to support that and how to have supportive conversations with people. Not everyone has to become a psychiatrist or counsellor, but you need that ability to do the basics, and of course that's primarily a training requirement at the beginning, but of course you then need time and you need an environment that's conducive to practise those skills. Otherwise, you can have all the training in the world but it's not going to happen in a hectic, traumatic environment where your own mental health often isn't looked after very much. The NHS isn't always a great employer when it comes to the mental health and well-being of its own workers.

So, I think there is a crucial thing here about ensuring that the services that people get treated in are sufficiently psychologically informed and they have an understanding of what trauma is. Many people experience things, particularly very serious physical illness, and that's a traumatic experience in and of itself. And of course, if you've had traumas in the past, that may be even more frightening for people. And there is this range of emotions that people experience when they're being treated for serious physical illness or long-term illness, that are often poorly understood. So, I think it's crucial that there is that understanding, but that's got to come alongside the resources to really care, and you do need that on-tap mental health support from specialists and experts, from people who really know their way around this stuff, and, indeed, people that can provide people with support for practical needs to make sure they're getting the benefits they're entitled to, that they're being supported to maintain their work, their childcare responsibilities, the other things that are part of life.

Thank you, Andy. The approach should go towards a trauma-informed approach—we've heard this in previous sessions before. Would you agree that also means that the professionals—? We understand the training and the time to train and how many are overworked in the NHS currently due to pressures, but do you also think that means that they need the flexibility to deal with certain patients? I had a constituent whose carer essentially said, 'We don't know how to deal, and the professionals don't know how to deal with the individual, the patient'. So, is there a case for flexibility within what we would like—a trauma-informed approach?

The thing is that no two people's needs are the same and no two people are the same, and you can experience traumas in your life without experiencing trauma symptoms later. But, equally, you only need one and it can have a really serious effect. So, there is something about understanding the individual, and I think it's really encouraging that you started with the conversation about person-centred care. So, the individual, if you like, their experience determines—and their needs determine—what kind of support they get. But, inevitably, in a system where you've got very short appointment times, if someone's asked about their mental health, it may be very brief and cursory. Sometimes, people may need two or three attempts to share what they're really feeling and how difficult it is for them. Many patients say they don't want to bother health professionals because they can see that they're busy and stressed out, so they don't want to share how they're feeling and what they're going through. So, creating those environments and having, as you say, the flexibility to provide that support when people are ready to ask for it is incredibly important, but we know it's challenging in a system that is running to stand still all the time.

Thank you for that. I'll open back up to all members of the panel. The committee heard some evidence suggesting that some patients may fall through the gaps because of the communication issues—particularly inadequate digital systems within the healthcare system. Is there a need for better communication and collaboration in the healthcare system, particularly around chronic conditions? I can see Professor Walters nodding. Perhaps you want to come in on the back of that question. Is there a need for it? What are the issues we're seeing at the moment?

Yes, I think there is a definite need for it. One thing we know from the research evidence—this applies to Wales, but also internationally—is that when those with severe mental illness present to physical health services, they get seen later, they get investigated less comprehensively and they get treated less aggressively. The means of rectifying that, in part, lie in the communication. I think mental health services have been really forward-thinking in developing electronic health records in Wales and there's now the national roll-out of a system in that respect, but it's in mental health and social care, which that doesn't relate to the systems in physical health care. So, it's not possible to cross-refer via that system, for instance. So, whilst that has real potential for sharing communication within mental health and social care, it doesn't have a facility to refer to cardiologists or to access laboratory systems in the way that it should. So, I think at the system level, the informatics could be better if we're going to solve this dichotomy between mental and physical health that exists within services.

Have you finished, Jack? Joyce wanted to come in, but do you want to—?

Can I come in at the end?

That's fine. Thank you, Joyce.

It follows directly on from what you've just said there about physical illness and mental health services. Would you also agree that communication needs to go the other way? If someone presents with severe mental illness, they are likely—very likely—to have physical conditions in the future. That communication then, the channel, needs to go both ways. 

Yes, absolutely, and it doesn't go both ways at the moment as effectively as it should. 

If it doesn't, what can change, then? What can be the difference to make sure it does, or is that a deeper issue?

It is deeper. I hesitate to say that there will be easy informatics solutions for this, because we probably all know that NHS informatics systems are complicated to overcome, but that would be a potential solution for that communication. But it's also just both parties appreciating the other's requirements and needs, I think, and often that isn't the case. The communication between specialties happens pretty well between secondary care mental health services and primary care—and the majority of physical healthcare is delivered by primary care practices, which is important to note—but within secondary care, it is difficult. And as I say, the systems could allow that. Certainly, access to laboratory systems readily within mental health would be really good, and that is patchy at the moment.

I know I said I was finished, but why is it patchy? What is the problem? Is it an issue with having access, or a perceived issue with having access, or is it just that it doesn't really happen?

It doesn't really happen, to be honest. It might do if you're on a ward in an in-patient setting, but in the community setting—the community mental health teams, which, again, is the environment in which the vast majority of care for those with severe mental illness is delivered—to get access to straightforward blood results, let alone radiological results, is really challenging. And often, clinics are still working with hard copy full blood counts, which is quite antiquated in many respects.

Thank you. Sorry, Chair.

Joyce, do you want to come in, then we'll come on to your section after?

I want to speak about neurodiversity and how that is dealt with, particularly when it's not—and I'm gong to talk about autism here particularly—immediately obvious that somebody is autistic, has neurodiversity as part of their make-up and can't express necessarily the way that they feel. My question is this: is it recognised enough within the system, and, if individuals present with neurodiverse conditions, are they treated as a person, as an individual, who might have other needs as well? Because I've read many articles where individuals have raised concerns about the fact that they're seen, first of all, as somebody who's neurodiverse rather than having their wider needs underneath.

Who wants to address that? Ollie, do you want to come in?

Yes, absolutely. I think it's a really important point. I think there are several ways to maybe respond. I think there's something really important about our environments of care as well—our actual physical environments are very traditional, are very set. They don't suit every person and it absolutely is the case that someone who is autistic is very different from the next person who is autistic—we are all individuals and I think that we need to recognise that as well.

Some of this is about, right from the estate, right to how we work with and value everyone. And it comes slightly back to this earlier, initial question around patient-centred care as well. So, I think there's an increased understanding of the need. We're not there yet—we absolutely aren't. And I think this is where, certainly, Andy spoke really well at the start about holistic care and patient-centred care—this is looking at people's individual needs as well. But I absolutely recognise what you're saying about people feeling that services are sometimes hard to access in that way.

Professor Walters wants to come in as well, Joyce.

I just wanted to highlight one thing at the very severe end of the neurodiverse spectrum, namely intellectual disability. Colleagues in Cardiff University, probably a decade ago, were part of an initiative to set up regular physical monitoring via primary care practices for people within intellectual disability services, and that's rolled out UK-wide now, whereby there’s an expectation—coming back to what we were talking about initially—that there's an annual physical health review for those people that is individualised. A lot of those people are uncommunicative, and so it relies upon taking account of their individual circumstances as part of that assessment. I think that's helped bring certainly GPs and primary care practices up to speed, as it were, with doing these kinds of holistic assessments in that group, and that might offer opportunities to expand to more neurodiverse populations. But I completely agree with the question there; it's not done as well as it could be.

I'm going to move on to well-being. We've been told that a health literacy campaign is needed to support populations in understanding health better and how to self-manage mental health and well-being. If you agree with that, how does health literacy around mental health need to be improved?

I think it's a really important question. I do absolutely agree with the point around improving upon health literacy. I think there's an important distinction here to make as well. We sometimes assume that someone who is living with a chronic condition or an illness is permanently going to have low levels of well-being, and that's absolutely not true. I may have an illness, but I would still experience joy, happiness and the things that are important to me. I think when we consider the types of services that should be available for people to improve upon their well-being, they need to be accessible, regardless of whether you've got a chronic condition or not. I think I'm just keen to make that point, because when we venture down things like social prescribing strategies, frameworks for well-being, we really need to consider everyone in society, not the people who are already experiencing quite positive levels of well-being routinely.

I can see Andy Bell wanted to come in as well.

Thank you. This is a really important question, I think, around mental health literacy. We’ve seen huge steps forward in mental health awareness and visibility over the last 10 years, and we're beginning to see that that's moving towards greater mental health literacy. But we have still got a way to go, and it's incredibly important that we really think about this, because some of those great improvements in terms of being able to talk about mental health, particularly for younger people, as part of everyday discussion and narrative, are a huge step forward.

We were lucky enough to evaluate some work that Children in Need have done across the UK that supported particularly building literacy among children of primary and early secondary school age, and what that showed is that public information campaigns are great, but actually, mental health literacy happens in relationships. It happens in relationships with trusted adults, whether they're in your family, whether they're at your school, whether in civil society, Scouts and Guides, that kind of thing. And so it's really important we give trusted adults the materials and the wherewithal to have those conversations with children, and to do that in a way that is a safe, of course, for them.

And so this isn't just about giving information to the public in a loudspeaker, traditional way; this is about how we invest in education and in families so that there is that ability to really create good mental health and give people the skills and knowledge, remembering that the things that put our mental health at risk aren’t necessarily inside ourselves; they're in our relationships, they're in our communities, they're in the inequalities between us. We very often, again, if we have a general population approach, tend to ignore the needs of the most marginalised groups in society.

Again, autistic people may miss out on mainstream campaigns. There needs to be an understanding of the particular challenges facing people from racialised communities, people with physical disabilities, those living in poverty. Generic information or awareness campaigns very often make inequalities worse, unless they are really attuned to that.

So, how do we improve on it?

I think it is about creating resources that allow for mental health literacy to grow in the relationships we have. So, for example, putting it on the school curriculum and making sure that teachers are well trained and supported in how to do mental health education well. It's one thing having it on the curriculum, it's another thing doing it in a way that actually really works. It's about creating resources for families and often it's about working with communities. I think some of the most exciting examples we've seen that have been about building mental health literacy have happened really very locally. So, for example, training pastors in hairdressers and barbers to have conversations about mental health with people and having that very basic level of understanding, so that you can create good mental health and well-being in the places where they feel comfortable.

Okay. I'm going to ask a question to the Royal College of Psychiatrists particularly. You evidence that technology enabled remote monitoring in schools, the TERMS project, led by TEC Cymru focuses on young people with eating difficulties in school. What could be learnt from that project and could similar projects be used to support self-management of maybe other conditions?

Professor Walters, do you want to come in on that one?

It's beyond my area of expertise, I must admit, eating disorders. I'm not involved in the delivery, so I hesitate to make any judgment on it. Ollie may know more.

Ollie John has indicated to come in on this one.

Yes. I was involved in this particular project with staff and TEC Cymru and we did have a visit from both the health Minister and the Deputy Minister for Mental Health to one of the pilot projects in there as well. So, the project itself was looking at the range of monitoring tools, digital tools, that could be made available to schoolchildren through a kiosk, where they would essentially take a number of readings that could then be presented on a dashboard and be made available to clinicians as well, which would help that individual understand everything that was needed in terms of their ongoing care. The feeling was that this could be better placed in a school environment than actually going out to a clinic for some fairly routine things that are part of someone's care package.

The actual use of the tools are things like, obviously, weighing scales and things like that, but more to the point around pulse oximeters and ECGs and those sorts of things. The understanding was that this could be utilised for other things, such as anti-psychotic medication prescribing. People's ECGs are telling around the suitability of the medication they've been prescribed. This isn't for eating disorders, by the way, this is for other things. But the specific example is to test the methodology for using something like this.

The feedback from the schools is all the actual interaction, the engagement, the design of the approach, was co-produced with young people in schools, supported from the Health Foundation through a pilot grant and then considered by Welsh Government as well. It is being considered amongst the long-term plan for mental health and the strategy. Obviously, it does raise a lot of questions around how young people access care and support, but at the heart of it is an understanding that certain things can be self-managed, can be monitored thorough a very non-medicalised approach, but also where a lot of young people would wish to receive care.

The point I made about ECG and anti-psychotics was we need some further investigation to say, 'Well, actually, would this methodology be suitable for elsewhere in the health system too?' So, it has been considered for things like ADHD medication management. Can we avoid sending people to clinics for quite routine things, where they could be seen at home through digital technology as well? So, it's in that kind of area now that it's been given to Government to consider. I'm hopeful that that work that has been undertaken will inform a next stage.

Okay.

Thank you, Joyce. Mabon ap Gwynfor.

Who would like to go? I can see Andy Bell.

Yes, there's so much we need to tackle here. I think the first thing is we have to acknowledge the social and economic determinants of both physical and mental health, and acknowledge that, often, poverty, racism, discrimination, deprivation, they have an effect on people's mental health first, and that often has a knock-on effect on people's physical health. So, the fact that people are experiencing such terrible physical health inequalities, they often start with poorer mental health. So, I think the first thing is we have to look at how we can tackle poverty in the first place.

One of the most important things you can do to improve the nation's mental health would be to tackle poverty and inequality. We know that more unequal societies create higher levels of mental ill health, and if you take people out of poverty, if you put more income in people's pockets, particularly those who are the poorest, if you make sure that people are getting the benefits they're entitled to, supported to get work, children from the most deprived backgrounds are supported to do well in education and get a fair chance, that that will reduce the burden of mental ill health in deprived communities, and that will have a knock-on effect on physical health. 

Inevitably, of course, we need to think about ways of mitigating those effects as well. There was a piece of research very recently that found half of people with a mental illness in the north of England were living in food poverty, and only about a third were food secure in any way, shape or form. So, when we talk about the mortality gap, the life expectancy gap among people with a mental illness, we have to remember that this intersects hugely with economic and social inequality, and, indeed, the gap in terms of life expectancy is higher in deprived areas than it is in wealthier areas.

So, there are lots of things that we can and should do. We should be investing in early years support in the most deprived areas and ensuring that—. If you look at the incredibly positive effects that Sure Start had—and we're still seeing some of those positive effects now, because they were really sustained, even when some of those children's centres unfortunately closed down—what they managed to achieve has still improved children's results later on, 10 years down the line. So, there does need to be a long-term approach here, there does need to be specific action and, of course, we need to ensure that people living with a mental illness, or who have a mixture of mental and physical health needs, get access to the very best advice and support with housing, money, debt, work. These are things that can help to tackle the nexus between poverty and mental ill health, which still has far too much of a strong hold on people's lives.

We've just looked, with Age UK, at mental health support for people in later life—again, this is across the UK. I think what we found is that, in a sense, mental health support in later life has been chronically poor, and whether there are specific challenges in older people's mental health services specifically now, I think what we can say is that mental health in later life has been overshadowed, is being ignored; there's very little support for well-being in later life. There is this pessimism, this systemic ageism that goes through services, and you can see it at national levels, where mental health strategies tend to just ignore older people entirely.

Mental health in later life is often just lumped in with other adults, and you get phrases like ‘adults and older adults’ used to describe services. Largely, after the age of 65 you’re pretty much forgotten until such a time as you develop a dementia condition, for example. So, all those opportunities to support older people to have good mental health, to tackle depression and other mental health difficulties in later years are entirely missed. And yet we know that NHS talking therapies have some of their highest success rates—in fact, the very highest success rates—when they do work with older people. So, there are often simple, relatively straightforward interventions that can help.

Of course, it is important to say that, in later life, one of the biggest risk factors to mental health is having one or more, and often several, physical health conditions. But, again, what we tend to see is that people’s mental health is overshadowed. It’s almost taken as inevitable and unavoidable that, if someone is living in later life with physical health needs, their mental health is bound to be bad, and there’s nothing you can do about it. I think we really have to shake away from that attitude and really think that there are always things that we can do at any time in life to promote good mental health, to provide immediate and quick support, to enjoy good well-being, or to get back to good well-being, and of course to provide those specialised services for people that need that little bit more. We still hear about misdiagnosis—people with dementia being diagnosed with depression, and vice versa—and that really is deeply troubling.

but I'll answer in English, if that's okay.

Yes, absolutely, I think that the needs of people in care homes—. It follows on from your previous question around how we perhaps forget about the mental health needs of people as they go through life. We’ve traditionally—and I think Andy, forgive me, touched upon this—quite often, services consider an adult population as both anyone over 25 up to 65 plus, and we don’t distinguish the needs of older adults. Likewise, quite often when we move people to different settings for their care, it wouldn’t be community based, it would be nursing home community provision as well. I suppose there’s another layer of stigma that we encounter too. So, there is definitely something about how we integrate care between different settings, particularly in older people’s care.

I think some of this comes down to staffing and culture. We do know we have real challenges with vacancy rates for nursing, for care workers out in the community as well, and I think this really does impact upon the services that can be delivered. I think the transitory nature of the workforce that we’ve got as well isn’t great for designing the services that we need to put in place as well. I think there probably is something about awareness sometimes of the care that is received, and the integration in care home settings too. I think that is something that—. We’d certainly be keen to write to the committee with a few further thoughts on that particular topic, but it does often feel that people are moved to certain care environments and perhaps forgotten about. That was the reason behind that particular comment about integration, really, and awareness of what that care looks like.

Joyce, do you want to come in?

Just on—

Yes, I suppose—. Again, I work with general adults, but I am conscious of the fact that people with very severe mental illnesses are cared for in care homes as well as those with other medical needs, particularly around dementia. It's really challenging, and Andy rightly pointed out the difficulties in differentiating between depression and dementia. It's a clinical conundrum often that isn't obvious how you differentiate between those two things.

I think the theme across the last few questions that stands out for me is that there are groups under-represented in many ways that just don't get access to the kind of public health campaigns about mental health literacy. And the way around that is to target them as part of the strategy for these campaigns. So, we face the same in research. These are groups that are under-represented within research. The evidence upon which we're basing recommendations—. People in care homes don't participate. People in minority groups in so many ways don't participate, and so within the research context, there's pretty good evidence now that targeted interventions to improve participation rates is the way to go. And so, I think as part of any policy that is looking to improve public health, literacy in any context, but also care, you need these targeted strategies as part of that.

Joyce, did you want to come in with a quick question? We're very short on time. 

Yes, a quick question. When we're talking about older people, we'll be talking about loneliness and bereavement in many, many cases, and the deterioration can be fairly rapid from those events. But the one thing that has helped in the past has been looking forward to something like a day out in a day centre, or a group, so that there's something for people to look forward to. And groups are talking to people who will understand how they feel. It doesn't require any medical intervention, but it's cost-effective. And we know that budgets are squeezed, but it doesn't seem to me that there's any interaction between local authorities and health authorities in this space. So, have you come across any good examples where that is the case, especially when we're talking about a climate of squeezed budgets?

Okay, I'm going to have to—. We've got other sections—. I'm really sorry to ask, Professor Walters, did you want to come in on that, but can it be a really short answer because we've got two more sections we're going to need to cover in the next eight minutes?  

But it's important. 

I can't think of any examples of that, but I acknowledge that it's an important thing to happen. But I haven't got any good examples, so it will be brief. 

No, no. That's fine. Thank you. Gareth Davies. 

Thank you, Chair, and good morning, everybody. I want to focus on prevention, if I may. Welsh Government have outlined a shift to prevention, so how, in your opinion, do you think we get there? And what role can mental health professionals play in that path to a preventative model, in your professional opinions?

Ollie. 

Yes, a really important question. I think we've touched upon some areas around the physical health relationship across health and care, which I think is really important, right at the start of this session. So, the culture around asking those questions, having the time, but also the—. Perhaps not time, but the culture to make sure that we're, as mental health physicians, asking the right questions and vice versa, and putting those things in place. 

I did want to make a quick point around prevention as well, in terms of people who often have a severe and enduring mental illness, and it's sometimes prevention in context. So, prevention for some people will mean what do they need in place to reduce the risk of readmission to in-patient settings. It's not always about never becoming unwell, even though that's obviously a key focus within this too. And I think when we consider everyone who is living with an illness or a chronic condition, it's what that prevention looks like for them is a really key point too, and something that we continually press upon Welsh Government, that it's not always people who will never otherwise become unwell, but people managing an illness as well. 

Professor Walters. 

If I could just step in and say, for the sustainability of health services in an ageing population, prevention is definitely the way to go for multimorbidities and these chronic conditions, and what works for people generally also works for those with severe mental illness. That's the general message, I think. But as we've said throughout, that perhaps needs to be better targeted to the groups that normally don't receive that message in the way that others might. And so, that applies to those with severe mental illness, those with neurodiversity, perhaps particular ethnic groups—so, south Asians, for instance, who are particularly at risk of similar multimorbidities, but are under-represented in how those messages are delivered to that population. So, I think it needs to be done in a targeted sense, but the preventative measure is absolutely crucial.

Thank you. And given we're talking about mental health and chronic conditions, what systems can be improved in terms of communication between certain departments, between mental health and physical health services? We use the links with kidney disease as an example. So, what better communication streams can there be between departments, to make sure that there's more fluidity in that process and there is a bit more enhanced communication between those departments, to get that holistic model into place, so that there is support available on either diagnoses or going through their journey through that particular illness, if they so need it?

So, it was interesting, on the Today programme yesterday, Professor Sir John Bell spoke about setting up outside of health services prevention services nationally, essentially, and saying that those don't sit best within health services. And I think that's probably right. It's almost too late by the time people get to health services to think about prevention, and it does need to be—. It's what used to be public health, but has been disinvested for years and years. So, I think that's the way that this should be delivered, not through health services, because, by the time people get to us, it's almost too late in that regard.

Having said that, for secondary prevention—so, for people who've already got a condition, to stop them getting further conditions or to stop them having worsening outcomes from that condition—then communication, as we've already said, between specialties is absolutely key. And I think mutual knowledge and informatics, as we said, will be key for that.

I think Andy Bell wanted to come in as well.

Thank you. I think what Professor Walters says about prevention is, of course, incredibly important. I think that, when people are using services—for example, if someone is in a kidney care service, whether they're receiving dialysis, or they've had a transplant, or at any other stage—then a liaison model could work really well, so having mental health workers within the renal service and mental health workers who understand what it's like and what it means to have kidney disease. And you can see the same across any physical health condition. It's what people with long-term conditions are constantly saying they want: they want mental health support from someone who understands what it's like to have diabetes, what it's like to have a heart condition, what it's like to have cancer. And so, I think that can work really well, and of course it works the other way too: having liaison physical health workers within mental health services. So, I think there is something about creating more permeability and having people with that understanding of either mental health or physical health within the systems of the other. And ultimately, that would be a very cost-effective model to provide people with that more holistic support. It would take quite a bit of investment, but I suspect that investment would pay itself back many, many times over.

Thanks very much. Ollie, any additional comments?

Yes, I think just to bring in an area around employment support, actually. There are some really well-reviewed, well-evaluated programmes. There's one called individual placement and support, which is having a link worker, an agreement between health and an employer, to support an individual with a diagnosed illness back into work. And the outcomes for that individual escalate massively—everything from decreasing risk of readmission, right through to that person having hope, having purpose, and a means to an income as well. So, I think there's definitely something in this about expanding that programme nationally. It's been well evaluated, there have been pilots in north Wales for several years now, and I think that should be a fixture of any mental health plan, going forwards.

Thank you very much.

Thank you, Gareth. I suppose, at the beginning, Ollie, you mentioned that you had some potential recommendations, so I'll ask you, but I'll ask the others on the panel as well: in the context of the work that we're undertaking, what would you suggest should be our recommendations to Government, from you perspective?

Yes, absolutely, I think, just following on from that point, I'd really welcome a recommendation, some investigation around that link between employment support and chronic conditions, and whether we can take forward national programmes based upon some of the pilots that we have had in Wales that are well established. I think that could be quite transformational. So, that would be the main one for me, and I think one of the themes, which has really emerged, is around very targeted health literacy for people with an existing illness. I think some scrutiny on that area would be really welcome.

And, I promise, the last one from me, which is something we haven't maybe delved into too much, but it's about bipolar disorder. The wait to access diagnosis or treatment times is very, very long, and I think Bipolar UK have been very vocal, understandably, about having a clinical audit in Wales to better understand this. And I think that's something, again, that is worth investigating.

The only thing I'd say about that is that there is this infrastructure for the national clinical audit of psychosis that exists that is driven by the royal college, and I think, for that to be successful, it's got to have support from resource to implement it. But it would be a shame to set up something separate for bipolar disorder that doesn't build on that existing resource, because I think that's been a real success in its implementation. So, it's worth thinking about that national clinical audit of psychosis in order to inform that, I think. But I fully support its value.

Anything else from your perspective, Professor Walters, in terms of recommendations? 

If we're thinking within those with severe mental illness, what used to happen and doesn't now is free gym membership for those under secondary care, and I think there have been those initiatives, for instance, for people with Parkinson's disease, of late. I think those kinds of initiatives can make a real palpable difference for people, and so to think about simple initiatives like that would be really helpful, actually, to improve activity.

The other thing is around smoking cessation and smoking education, and, really, that would make a big difference. We don't yet know how vaping is going to impact, but it's likely to be beneficial in the broader sense. Sorry, less detrimental rather than beneficial. Yes, that's the other big area.

Thank you. Andy Bell.

I can give you a list of recommendations as long as my arm, which I won't, because we haven't got time, but I think just to focus on some key areas. The first would be that we really do need a whole-of-Government approach to mental health, and that includes having real ambition around tackling the determinants of mental ill health, particularly poverty and particularly racism and discrimination in all of its forms, because we know that causes so much distress in the population—needless mental ill health that could be prevented.

I think we need to see a relentless, targeted and specific approach to reducing the life-expectancy gap for people with a mental illness, and that really does require, again, systemic action—everything from supporting people when they're ready to stop smoking to stop smoking, to tackling poverty and food insecurity, and to giving people the right support with their physical health, including access to screening and vaccination programmes, for example.

And then I think, crucially, we need to see real investment in mental health support in physical health services for people living with long-term conditions, so that no-one is left with their emotional health and well-being overshadowed or ignored when they're living with a chronic condition, and that that support is tailored around their needs in a whole-person-care type of approach. There are lots more things I could say, but I should not.

Yes, Professor Waters.

Can I just come in very briefly and say that, within the neuroscience and mental health space, it's one of the most successful research areas in Wales? The UK research excellence framework ratings bear this out. And I think there's real potential to link the activity that's going on on the research side with clinical services and clinical service development better, and that's something that is worth emphasising.

One example of that is that we were awarded the only mental health multimorbidity grant from the Medical Research Council that is led from Cardiff, but involves Bristol, Bradford and others, and that's looking at the early signs and signatures of multimorbidities of depression and cardiovascular disease particularly. So, ensuring that we facilitate avenues for that to happen, and for that to inform Government as well, is really key. So, I just wanted to emphasise that. Thank you. 

Thank you. And, Ollie, you mentioned health literacy. What would be a specific recommendation around that?

I think there's something in ensuring that our health literacy is targeting specific groups who have a chronic condition. I think that is it. It's almost like a stock take in that respect, because, as heard this morning, for people with, for instance, a kidney condition, and the associated psychological challenges around that, are we reaching out to those, are we reaching to marginalised communities too? And it is absolutely the case that our most vulnerable have the least advocacy, so we need to be really targeting that work. So, I think it's a bit of an analysis and a bit of pressing on Government to say, 'Are we doing that work in a way that is giving any merit?'

Okay. Thank you, all, for being with us this morning. We really appreciate your time and professional input as well. So, thanks ever so much. And I think, Andy, you mentioned that you've got a list of recommendations as long as your arm, but, by all means, if you wanted to e-mail some further recommendations to us, we'd obviously welcome that from any of you, if there's anything else you want to add. But we'll send you a copy of the Record of Proceedings, and if there's something you feel is important to us and that you want to add to what you said, then, by all means, do that. But, diolch yn fawr iawn. Thanks very much for being with us this morning. 

Diolch. 

Thanks.

Thanks. I'll move to item 3, and I propose, under Standing Order 17.42, that the committee resolves to exclude the public from items 4, 5, 6 and 9 of today's meeting. Are we all content? Thank you. In that case, we'll move into private session.

Bore da. Welcome back to the Health and Social Care Committee. I move to item 7, and this continues our work in gathering evidence to inform our inquiry on supporting people living with chronic conditions. I'd like to welcome our two witnesses this morning, and perhaps you could just introduce yourselves for the public record. Sir Frank Atherton.

I'm Dr Frank Atherton. I'm the Chief Medical Officer for Wales.

I'm Nick Thomas. I'm the assistant private secretary for the CMO.

Thank you, both, for being with us this morning. If I perhaps ask an overarching question, it gives you perhaps an opportunity to set out some wider comments as well. What particular challenges do you think we have in Wales in reforming healthcare to provide person-centred care to those living with chronic conditions, and how could any barriers that exist be overcome?

Thanks, Chair. The starting point for me on this has to be the rapid change over my career that I've seen in the epidemiology of disease—in the UK generally, but in Wales in particular, of course. When I first qualified in medicine, a lot of the focus was still on infectious diseases, but, of course, non-communicable diseases were absolutely on the rise, and there were lots of investments in those areas of, often, long-term diseases, chronic diseases, if you will. But the biggest change, I suppose, in more recent times has been the move from a focus on single-disease issues—heart disease or lung disease—to recognising the fact that people suffer from more than one chronic condition, and the rise of multimorbidity, as we often call it. And that has gone hand in hand, of course, with the demographic transition, the demographic changes that we've seen in Wales, where we are, of course, an ageing population, we'd recognise that, and that brings all the problems of multimorbidity and having more than one disease.

When you ask me about the barriers, I think what I would start with is the way the workforce is shaped in the NHS, certainly in healthcare, less so on the social care side. But, on the health side, we have, for a generation now, been training people to be specialists and superspecialists, often, in conditions—and we do need specialist assessment and we do need superspecialist treatment occasionally—but that has been to the detriment, I believe, of general medical knowledge and general medical understanding. And, to really treat multimorbidity and multiple chronic conditions, especially in frail, elderly people, I think you need doctors, clinicians who have a broad understanding of a number of conditions, not just, not solely a detailed understanding of a single condition. So, there's something about how we build the effective workforce to deal with multimorbidity. That's about doctors, but it's not all about doctors; it's about the broader healthcare team around them and making sure that that's well organised and well developed.

There is something also about the way that we use our health system. Primary care, as I'm sure we all would recognise, is very significantly overloaded, and we need to think about how primary care can best meet the needs of people with multiple chronic conditions. Primary care is the place where most health service should be provided, but it's under significant stress—we may want to go in to some of that at some point, Chair.

On the secondary care side, of course we have a significant problem that our hospitals are overloaded, and they're not fit for purpose in terms of the ageing infrastructure that we have here in Wales and across the UK. There's clearly a need for significant capital investment to make those facilities fit for the future, and this is a time when it's very difficult for Government, I think, to attract capital investment. So, that's going to be a major challenge, going forward. I'll maybe stop there, because I'm sure there'll be areas that you'll want to delve into a bit more in detail, Chair.

Yes. Thank you, Frank, for that. There'll be some areas I know that Members do have questions on. But, perhaps, one of the areas you mentioned was the need for training, not just for GPs, but for other health professionals as well in terms of maintaining both their specialist skills and perhaps their general skills as well, and I just wonder how the education and training that you refer to could be improved on.

Yes. So, if I think about doctors—and we do think about other clinicians in the system, but if I think about doctors first of all—it starts with undergraduate education and the way medical schools work, really. And I think, actually, in Wales, we have big opportunities with the new medical school being established in Bangor, to look at what we'd really want the doctors of the future to be able to do, and to make sure that they are well suited to being generalists. I was involved, some four, five years ago, in the selection process around the new medical schools across the UK, not just specifically for Wales, and I was a member of a panel that looked at the various bids that came in from universities, and some of them were very traditional bids and would have involved creating much more of the same. But others—and I think this is where Bangor has the big chance—were much more focused on developing doctors who would be working in rural communities, as we have in Wales, and working in primary care settings as opposed to secondary care, acute specialist services. So, it's making sure that we have a pipeline of future medical professionals who are geared to (a) dealing with multimorbidity, understanding broad systems, and (b) working in communities, and, specifically, of course, in primary care. So, it starts there. Then, of course, there's higher medical training, which is also very important. I think we're very fortunate in Wales; Health Education and Improvement Wales I think does a very good job, tries to take a very broad multidisciplinary focus on the workforce, but there's always more to go at there.

The most recent initiative, again at UK level, has been 'Shape of training'. Actually, I, along with other chief medical officers, wrote an article on this some three or four years ago. But 'Shape of training' does recognise that we need to move the medical workforce from a super-specialist workforce to a more generalist model. Sometimes you need both skills—you need to be a generalist, but you need to have specialist skills on top of that. So, 'Shape of training' and making sure that's fully rolled out and that that is as effective as it can be here in Wales is really quite important.

Thank you. Joyce, if you could come on to your next set of questions as well after this. 

If we do train people with a broader spectrum of understanding—generalists—in Wales, individuals are concerned about their own profession as well. So, the question from me would be this: how would that fit for the individual if they were trained as a generalist rather than a specialist in moving forward in their own career? And how well would it be recognised elsewhere?

I don't see it as an either/or. I think there is something about having more generalist skills within the specialists, really. I think you need a very strong base of general medical knowledge. I do worry that, over the last perhaps two decades, we've moved too quickly away from the general medical core knowledge towards that specialist training. It's about making sure that the specialists really understand—. I'll give you an example. In Wales, if someone sees a specialist for a certain condition, and then something else comes to light, that specialist has a number of options. They can refer back to the GP, who then has to screen the patient again and send it back to another separate specialty, or the doctor can make a specialist-to-specialist referral. But in way, that specialist should be able to apply at least a general medical knowledge to the patient that's sitting in front of them. And maybe that's at the heart of the matter—it's about looking at the whole patient, not just at the organ or the bit of the patient that you're particularly dealing with.

Thank you.

Do you want to come to your questions, Joyce?

You want me to go on to my—? Okay. So, moving on, the Welsh Government committed in 2015 to people with long-term conditions having individual care plans, if they want them, of course. What we need to know is has the introduction of those individual care plans had an impact on improving the care and communication between the patient and the healthcare profession. 

I can really only answer that in quite general terms, I think, in as much as it's about that question again of seeing the patient as the whole patient. Has it bedded in yet? There's more to do. Can we demonstrate the impact of that? Well, it's kind of anecdotal, I suppose. People do like to have an individual care plan. I think they benefit from that. It helps to co-ordinate the care around the patient.

I'm not sure what metrics you might have in mind in terms of how you might measure whether there's been an impact. Good patient care requires good patient satisfaction. We do, sometimes, have patient outcome measures, and they can be measured through those kinds of ways, and through our national clinical frameworks that we introduced two years ago we are looking to use patient-reported outcome measures and patient-reported experience measures more effectively. So, I would expect, over time, that the use of individual care plans would achieve better outcomes in terms of PROMs and PREMs. But I don't have any hard data to say that that's happened yet.

The other aspect that I'm very concerned about—and I'm sure we all are—is the integration between health and social care, and the way that care plans need to cut across those domains. Frail elderly people—and we're talking about chronic disease here—are getting stranded, if you like, in hospitals, and it's the worst thing to happen for them, really. And so, making sure that care plans help with the transition of people from acute care back into the community, which is where they want to be and where they’re best treated, is really quite important.

And the final thing I would say on that is that care plans—and I'd perhaps include end-of-life planning around some of this—is something that we’re very conscious we need to do better in Wales. We need to help people to understand and to plan their journeys through the healthcare system towards the end of their life much better. I think we are making progress on that in terms of end-of-life planning and end-of-life care, but, again, there’s more to do.

So, I’m sorry I haven’t answered your question in terms of what impact, but I’m sure it’s the right direction to move in, to have individual care plans and to make sure that they work across the whole system.

You talked about generalists in some areas, and I want to talk about collaboration between different parts of the healthcare system, particularly when we’re talking about those with chronic conditions. Are the systems that are currently in place adequate to enable communications between those different professionals? It’s sort of the stage before the one we’ve just talked about.  

It’s a really excellent point. The simple answer is ‘no’. It’s not as good as it needs to be. We are one of the few countries in Europe that doesn’t yet have a proper electronic healthcare record. I know this is a priority for the Minister, and that would go a long way to improving the communication between health professionals. I think things have got better than they used to be. In some cases, it’s easier for general practice to talk to secondary care through Consultant Connect, for example. Those sorts of things do help, but they’re not yet systematically embedded, I don’t think, in our system sufficiently. An electronic health record that any clinician can access is really important. I think we need to consider the issue of patient-held records and what patients hold themselves. That would be a future ambition, I think. But, yes, there’s more to do in terms of the records so that people can communicate.

When I trained in medicine, there was a lot more interaction, I would say, between GPs and consultants than there is today. Some of that was through medical education, which has, to some degree, fallen a little bit by the wayside, I think. And also, of course, as I referred to earlier, the pressures on primary care in particular mean that, for busy doctors, and their allied health professionals, and nurses in the practices, finding the time to engage in interdisciplinary working with secondary care is difficult. I always feel that when doctors know each other, and know each other sometimes on a semi-professional basis, or through continuing professional development in a learning environment, some of the arguments and the pathways for patients actually become easier to navigate. It’s easier if you’re a GP, and you know the consultant cardiologist, to pick up the phone and talk to him or her and get your patient through the system if you see a patient who has urgent needs. But that, I think, happens less frequently now than it used to, and part of that, I think, is the business of the system and the lack of time and opportunity, which you could see, perhaps, as a bit of icing on the cake, or something which isn’t essential, but which I think is essential, about developing interpersonal relationships.

We did, about three or four years ago, develop a protocol in Wales. This was recognising that there was a problem on the interface between primary and secondary care. It was a protocol for working between those two parts of the system. I think that was quite useful. It's been very useful. But it's now a bit out of date. I've just been asking my colleagues who work in the Welsh Government—we have a couple of very highly skilled GPs who work part-time for us in the primary care directorate—to have another look at that and see if we can improve the way that that helps to smooth that interface between primary and secondary care.

Thank you. Is it possible for us to see that?

Yes, of course. Yes, we can do that.

That would be helpful. Thank you, Dr Frank. Jack Sargeant.

Diolch, Cadeirydd. Throughout this inquiry, the committee has heard that there has not been enough mental health support for those living with chronic conditions. Where do you see the improvements that need to be made?

Almost any chronic condition has psychological aspects to it or mental health aspects to it—there is no doubt. Whatever chronic condition you have as a patient, you're worried about it, you have anxieties about it, and having positive mental health can help to alleviate some of the chronic conditions. There's no doubt about that. So, I do think that there's need to—. This isn't necessarily about mental health services. It's about the broader mental health provision, having ways in which we, the health system and the social care system, can support positive mental health in people with chronic diseases, and that's not necessarily about referral into mental health services. Sometimes that would be needed, but it's more about providing access and signposting people to ways that they can build positive mental health.

I know you'll be aware, Jack, that we've invested quite a lot in Wales around social prescribing and trying to develop those pathways with the community sector, with the voluntary sector, so that people can better access those. So, that would be one part of the system. We also have, of course—. Mental health itself is a chronic condition, as you well know, and so making sure that we don't just focus on chronic physical health is really important to us in Wales. Again, institutional care should be the exception. We need and have developed stronger community-based mental health teams, but there is always more that we need to do. Those systems again are overloaded, so we need to make sure that people working in those systems are working at the top of their licence, that they're really seeing the people who really will benefit from them.

I do see it as a kind of pyramid where the lower-level support and almost self-support, self-help, is at the bottom, the social prescribing in the middle, and then the primary and secondary care towards the top of the pyramid. We need to make sure that that model is (a) agreed and supported and (b) that there's enough capacity in the system to actually deal with that. But I do worry about the volume of what you might regard as low-level but important mental health issues arising, particularly in younger people, actually, and there's more we need to do as a society. It's not just about the health system, but as a society, to tackle some of that problem, and that gets us perhaps into some of the prevention agenda, which is kind of where I'm going.

Thank you, doctor, for that. You said it's a challenge for society to deal with some of these problems. Would you therefore agree with the comments in the previous session that this isn't just a health issue, this is a cross-Government problem, and all Ministers in all departments should be taking a view to try and tackle this together?

I agree entirely. Positive mental health is something that cuts across so many domains. It does need a cross-Government approach. I would agree with that, yes.

Thank you. Just a final question from me, changing the lens towards those with severe mental health illnesses. We know, don't we, that they're at a higher risk level to have physical health problems. How should the health service—? How should it reflect those patients who have severe mental health illness? What should it look like for them to make sure that their physical health is looked after and not left behind?

Well, some of that goes back to my earlier point, really. I mean, if somebody is seeing a psychiatrist, I would hope that psychiatrist would have at least, you know, a basic understanding of general medical practice still, and would be able to recognise physical illness and make the appropriate sideways referrals into other services. So, there's something there. But also, I think it's important to acknowledge what you just said, which is that sometimes we can—. You know, people with enduring mental health issues—and particularly, as well, people with chronic conditions, such as learning disabilities—sometimes their physical illnesses are not really recognised. And so working across carers more generally, not just health professionals—not just doctors, not just health professionals—but more importantly with carers, so that people understand, you know, what is a serious issue that needs general practice support or needs specialist support, is quite important, really. It's about referral pathways, making sure that they're appropriate.

Thank you. I think we all agree with that. Just one of the comments that was made around communication between departments, say from mental health services to physical health services, was that perhaps that communication both ways wasn't quite good enough. So, I think that's probably an area that the committee would be interested in looking at, but I think I've taken my time. Thank you.

Thank you, Jack. Gareth Davies.

Thank you very much, Chair, and good morning—just about morning. I'd like to address inequalities, and in your 2023 annual report, you say that the gap in avoidable mortality between the most and the least-deprived areas widened to the highest level last year. How should we address these inequalities and what steps can we take to reduce that gap?

So, I'm a public health doctor, as you know, and so inequalities are something that I get really quite concerned about and that's why I've tried to focus on it to some degree in all my annual reports. I'm pleased that you referred to it. Thank you. And, of course, you'll also have noted, I'm sure, that, during the pandemic, the inequalities in health have actually widened, and so the poorest communities, members of our communities, have suffered the most and continue to do. It comes back again, I'm afraid, to a cross-Government approach. It's not something that the health service alone can tackle, but there are things that we can do within the health service. So, I always encourage every doctor, actually, every service within the service, you know, every specialism, to look carefully at what are they doing and what are the outcomes and how are the outcomes different for different segments of the population. And some services, I would say, are better at doing that than others—better at looking at their outcomes and disaggregating their outcomes according to ethnicity, according to income, according to levels of poverty, deprivation, et cetera.

We have had a couple of national initiatives to look at variations in outcomes. Specifically, there was one around cardiovascular disease about two or three years ago, looking at the atlas of variation, and I think that approach had somewhat stalled during the pandemic and we probably need to get back to some of it. Sally Lewis, who leads our work on value-based healthcare, has been a prime architect of some of this. So, I think we need to get back to looking, service by service, at what the outcomes are. But, you know, going beyond the health service and what the health service can do—and we do need to do more within the service—. We should mention the inverse care law. It is a fact, as I'm sure you're aware, the committee will be aware, that if you look at the distribution of healthcare facilities, particularly primary care facilities, in Wales, the most deprived communities actually have higher patient-to-doctor ratios in primary care than the least deprived, and that is something that we need to think about correcting. It goes back to that question about the workforce and how we train the workforce in the future. But beyond the health sector, I can't do better, really, than, you know, reiterate what Michael Marmot has said. He's a good friend of Wales, Sir Michael Marmot. I'm sure you've heard him speak at some time or seen his reports on a fairer, healthier Wales, and it's really a delight that Sir Michael is working with some of our health boards over in Gwent. Gwent is aspiring to be a Marmot region, and that's getting way beyond the healthcare services. So, this is recognising that they're important, but looking at things like child poverty, about a fair living wage, about access to good education, all of those that we often refer to as the determinants—the determinants are the things behind people's health—and trying to address those.

It'll be very interesting. It's quite early days, but in Gwent, being a Marmot region, it'll be very interesting to see if they can make an impact on health inequalities, because if they can, then we need to roll out some of those through local authorities, through local government, through the health service as well in other parts of Wales. But this, you'll understand, and I know you do, is a long-term challenge, and the short-term addressing of inequalities is really quite a challenge.

Thank you. Also in your report, and obviously a key component of some of these—inequalities is the problem with the cost of living and the increase in the cost of living, which is described in the report as a long-term public health issue. What impact, specifically, do you think that cost-of-living pressures have had on people living with chronic conditions, and what can be done to address that and perhaps put some further safeguards in place to protect people from those increases in the cost of living?

So, if you haven't already seen, and I'm sure you will have done, Public Health Wales did a very good, analytical piece on the cost of living and the impacts of that, and it's well worth reflecting on that. But broadly speaking, anyone with a chronic illness and they tend—of course, we're often thinking about the frail, the elderly particularly, and the direct impact of heating your house, that has become far more expensive. How do you look after yourself and do that self-care that I was talking about a minute ago when you can't afford to heat the house?

We've invested a lot in Healthy Weight, Healthy Wales in 2trying to promote healthy eating in Wales, trying to address some of the obesity problem—the weight problem we now face. It's much harder to eat healthily if you don't have the budget because cheap food is the unhealthy food. Unhealthy is cheaper than healthy food very often. So, those will be two very direct links, I think, between cost of living, fuel poverty, poverty generally, and the ability of people to manage their chronic diseases.

Thank you. Thank you, Chair.

Mabon ap Gwynfor.

I'm really sorry, Mabon, I pressed the wrong button and I moved to Welsh. Could you just rephrase it for me? I beg your pardon.

Thank you for that. So, I think—and I go back again, I'm afraid, to Sir Michael Marmot, who has spoken at great length on this—that we need to have proportionate universalism. I know it's a very, very big mouthful, but what it means essentially is that we need to provide good-quality services and support and prevention for the whole population. But then we need to really narrow that down and provide a more specific focus to the people who are in greatest need, and that is the way we try to address inequalities. 

So, to give an example, there are things we can do across the whole of Wales to promote—. I see healthy weight as a really good, important strand. Not the only one—you think about smoking, you think about alcohol, but let's take that as an example: healthy weight. We can provide health education across Wales in terms of healthy weight. We can try to support an environment through our planning system that promotes healthy eating. We can try and work with industries, supermarkets, for example. And we can do that across the whole of Wales and we need to intensify that, and I know this is an area that the Minister is—sorry, the Cabinet Secretary now—is particularly interested in. So, we can do that across it. But then we also need to recognise that there are specific needs within communities and we need targeted approaches. Let's take the example of basic cooking workshops to help people to understand how to deal with fresh fruit and produce. So, we need to support those things. We need targeted interventions on active living, for example, in the communities that are least active, which are often the more deprived communities, say up in the Valleys et cetera. And I do believe that those kinds of initiatives, those targeted things—although Government has a role in funding them and supporting them, I think they're better managed and planned at community and local level. So, I often look to the local health boards and the local directors of public health to manage that more targeted piece, and the role for Government, I think, is to try to provide the overall framework and the resources—the overall framework for what needs to be done at a pan-Wales level, and then the targeted resource should be managed at a local level.

I've just taken obesity as one example, but you could say the same for smoking, you could say the same for alcohol, you could say the same for many of the issues where we want to get much stronger on prevention.

Well, my own view is that it's variable, I think. Do we need to see better alignment? Yes, of course, we always do. Is there some degree of alignment? Yes, there is. We have possibly, arguably, too many structural processes in Wales. We have regional partnership boards, we have planning boards, we have public services boards. I often wonder whether they could be conflated, but I know that's a political decision that would need to be made.

But there are mechanisms to allow that co-ordination between the different sectors, between local government and the local health boards. I say it's variable; I do see examples of really good practice sometimes. As we went into this winter, as an example, we had a very fruitful discussion, I think, between all the medical directors of the local health boards—a group I chair often—and their counterparts, the directors of social care in local authorities. And so where you have—again, it goes back to about individuals knowing each other—that quality of interactions between a local health board chair and the leader of a council, between the medical director and the director of social care, I think you can get a lot done. And, yes, I think there are really good places where that works, but there are others where it becomes more problematic, and that's sometimes personality driven, it's sometimes finance driven, because let's face it, everyone is under the cosh in terms of the finance at the moment. But what we have to do, what we really have to do, is always put those considerations aside and think about, 'Well, what is right for the citizen? What is right for the patient in front of us?' And I always encourage medical directors to go down that route.

There is always more to do, and although I've talked about the preventative agenda being very broad and working cross-Government, across the whole of society, there is an absolute job for the health workforce to do that. I think general practice is pretty good at doing this. I think we miss opportunities in secondary care often. When somebody comes into hospital, say, with respiratory disease or they come in accompanying a relative who has chronic obstructive pulmonary disease or is having a heart attack, it's a prime teaching moment. It's a prime moment where the health workforce should be looking at this as a key preventative agenda opportunity.

We do try to do that. There's a programme, of course, called 'make every contact count', MECC, every contact counts, and that tries to make sure that we don't miss these opportunities to provide advice on healthy eating, on smoking, on alcohol and healthy living at every opportunity. But, of course, as ever, the devil lies in the fact that everybody is just terribly busy, and that is the major constraint, I think. So, is there something we can do to empower people more? Yes, there is. We can empower the workforce by giving them the skills and training that they need to raise what are often quite difficult issues with their patients. If you go to the doctor and you have a migraine or a problem with your leg or whatever, you don't go expecting them to start asking you about your smoking history or your alcohol intake, although I think that society is getting more used to that now. Sometimes, it's difficult for health staff to raise these kinds of issues, so giving them the skills and confidence to be able to do that is quite important. And also building the time into—and this is really the hard bit when the system is under so much pressure, but—building the time into people's job plans, into the work that they're doing and giving them the time and opportunity. What can you achieve in a six-minute consultation with a patient? It's very hard to deal with some of that.

One of my biggest worries, and this is coming out of the pandemic and it's something I've said to the public inquiry, is that we have very little—. Because we're so busy, we have very little redundancy in the system that would allow the system to get more engaged in prevention. Now, that's a constraint, and that's something we need to try and get around, but that's the way we need to go. We should expect every health professional having an encounter with a patient to think about the whole patient and what would make life easier and better and health better for that patient.

I think it's an absolutely excellent suggestion, yes. We do, as you know, have pharmacy schemes where people get—you know, minor ailments schemes, et cetera—but building it into those processes would be useful. Dentists, absolutely. Dentists do quite a bit of screening. They do quite a lot of screening. I did manage to go and see my dentist a week or so ago, and they asked me quite a lot about my alcohol intake, which was quite refreshing to see, that they can do that. So, it does happen in some—

What was the answer? [Laughter.]

I'll record that separately. [Laughter.] It was within the CMO drinking limits, Chair, let me put it that way.

And I would add to that, actually, the voluntary sector has a lot more to do as well. We need to engage broader society through the voluntary sector, because a lot of the contacts of people are with the voluntary sector, and that's another route we can also use. Thank you.

Yes, sure.

What we've seen as a consequence of the pandemic—. And, of course, it was a terrible time, we lost a lot of lives in Wales and we're still dealing with the issue of long COVID, but we also, as you know, we saw a disruption to the healthcare delivery system and that was most apparent, I suppose, in terms of waiting times and planned care waiting lists et cetera, which have gone up and which we're now trying to catch up on; there's a big backlog of care not provided in secondary care. But the thing that we were worried about when we looked at this as chief medical officers was the fact that some of the work that had previously been done prior to the pandemic within primary care in terms of, say, screening for cardiovascular disease, had dropped away. And that may well, we believe, be a contributor to both the increase in mortality that we've seen from cardiovascular disease post pandemic and also some of the inequalities that we were talking about before.

So, in terms of what needs to be done, we need to get back and, again, create the space in primary care so that people are having their blood pressure measured, people are able to have their cholesterol checked when needed, people are getting weighed and getting their body mass index recorded, and some of that, I believe, has fallen away and has not yet come back in a fulsome way. Again, sadly, it comes back to the issue of constraints and pressures on primary care.

It's a good thing, I think, that primary care has really adapted extremely well in terms of not just seeing everybody face to face, but even post pandemic, is still managing a lot of telephone consultations and video consultations sometimes, remote consultations, e-mail exchanges et cetera. I think that multiplicity of channels that people have is still not adequate, and often people do still want to see their doctor face to face, but having those routes is really important. But it makes it harder, sometimes, to do the secondary prevention of checking all those things I just mentioned. Now, again, I'm really pleased that you mentioned pharmacies, because pharmacies have a role to play in that as well. If you can get your cardiovascular risk score, risk assessment, through a pharmacy, well, why not? Why not?

Diolch.

Thank you. Just building on some of Mabon's questions and your responses, it seems that one of the obstacles in person-centred care is with health professionals perhaps working in their own silos rather than doing, perhaps, what you're suggesting and looking at the whole patient, perhaps beyond the scope of the dentist, for example, asking about other areas of your health. One of the obstacles, I would imagine, is the way contracts are and funding is constructed. So, it seems like an almost impossible challenge to get around that, but do you have any thoughts about how you could overcome that, so that health professionals can really, if they see a patient that they need to spend time with, they could think beyond that contract and funding arrangements?

Well, I guess the answer is to think a bit more holistically about those contracts and to make sure that you include in those contracts the softer things around the edges, as opposed to just the hard intervention that's in front of you.

Do you think that there's work that could be done in that regard, and any, perhaps, suggestions on how contracts could be developed in that way?

Well, I'm not a contract—. It's not really my field, but, if you look at what happened in England under the QOF, the quality and outcomes framework, some of that was built in through the QOF. The difficulty that arose was that it became too complex, too big, too unmanageable, really. So, I think we perhaps need to reflect on what the experience is elsewhere with the QOF and look at how we can strengthen that element of service provision—the prevention approach through the contractual mechanisms we have in Wales. But it's a good suggestion. I haven't given it a huge amount of thought. I think we do need to think about it further. Thank you, Chair.

And finally, and I suppose thinking about your annual report as well, in that context, are there are any key recommendations you think that we should be making in our work on this subject to the Government?

Well, as you know, my last annual report was focused very much on the commercial determinants of health. When we think about the whole of society, absolutely we need to think about what the NHS can do more, what different Welsh Government departments can do more, but we also need to think about what industry can do, and what the private sector can do to support us. A lot of our lives are lived outwith the realm of Government, and I think there's more to go at, in terms of dialogue with the private sector on how they can help us to build a healthier nation.

Okay. Well, thank you very much for your time, Sir Frank Atherton, this morning, for being with us. We're very grateful for your input into our work, and I shall ask you privately about your answer to the dentist on your alcohol consumption.

Diolch yn fawr.

Thank you for your time this morning. Diolch yn fawr iawn.

We move to item 8 this morning. We have three papers to note. We have a letter from the Equality and Human Rights Commission regarding violence against women and girls. I do note there's another Senedd committee conducting some work in this area, which I know will be of interest to the interim chair. We have a letter from the Older People's Commissioner for Wales regarding access to GPs in Wales, with a very useful report attached, which I know will help us in some future work that we're considering, and, finally, a letter to committee Chairs from the Chair of the Finance Committee regarding the scrutiny of the draft budget, and I know that we've discussed this, and I shall respond to the Chair on behalf of the committee in that regard as well. But are we happy to note the three letters? That's great. Thank you.

That brings our public session to an end today.