Health and Social Care Committee

I move to item 2, and item 2 today is our second meeting dedicated to taking oral evidence from various stakeholders to inform our inquiry on mental health inequalities. I'm very grateful to our witnesses for providing time with us this morning. Can I just ask you to introduce yourselves for the public record?

My name's Rob Poole, I'm professor of social psychiatry at Bangor University. I co-direct the Centre for Mental Health and Society, which is a research group whose interests are around the social dimension of mental health.

My name's Ewan Hilton, I'm chief executive of Platfform.

Morning. My name's Dr Jen Daffin, I'm a clinical psychologist, and I'm here as chair of Psychologists for Social Change Cymru.

Lovely. Thanks ever so much for being with us, all. Members will have a series of questions and don't feel you all have to answer every question—some questions will just be dedicated perhaps to some of you. I'm going to ask an opening question that I'm keen that you all give some opening comments on. Can I ask you what do you think are the things that people need to build and maintain good mental health? And, as a society, are we good at ensuring that those fundamental needs are met?

Who would like to have a stab at that first of all? I should say, any time, if you want to come in, lift your pen or hand up or something so that I can see you want to come in, if that's all right as well, and Members will do the same. Who wants to come in on that question first? Go on then, thank you, Professor Poole. Thank you.

I cracked first. Okay, so what do people need? Well, we know that mental health problems across the board are strongly associated with social inequalities and social injustice. We know that the most marginalised and deprived groups in society are most vulnerable to mental health problems. That isn't to say that other people don't get these problems, but it's about who actually does in large numbers. So, it's a bit like in the old days, tuberculosis, anyone could get it, but by and large the poorer part of the population got most of the TB that there was.

The most important thing in the long run is around prevention, and prevention is dominated by the need for better levels of social equality. This is not simply a statement of what is a social good, which I think most people would agree it's a social good; there is actually a mass of clear evidence. If we look at almost—. Well, pretty much all mental health problems are much, much more common in people from more deprived parts of the population. In particular for the more serious end of the spectrum, people who have problems with psychosis, this is particularly strongly concentrated on those who grow up in conditions of inner-city deprivation and people who grow up black in the UK. There's a very strong association with those two factors.

If we want to develop proper long-term prevention, what we need to do is address what Michael Marmot has described as the cause of the causes, which is the conditions under which people live, particularly during their childhood, but also in their adulthood. Now, that's a big ask. That's asking for a large transformation in a change that's been in the wrong direction over the last 10 years. I hope committee members will have had access to Michael Marmot's report of 2020, which demonstrates that, actually, right across the board, most public health indices have worsened as inequality has worsened following austerity policies.

So, that's about prevention, and we've got a strong emphasis on prevention, but there's also, obviously, a large number of people in society who have mental health difficulties. One of the things that is really important for people is social infrastructure. Once you've got mental health problems and you need to return to employment—we know most people with mental health problems want to return to employment if they can—. Housing and benefits. And are we good at addressing these problems? No, we're not. We have also seen that our services have become very atomised, very difficult to access, and are probably overly focused on controlling people rather than getting alongside them and offering the things that they need to recover. And that isn't just about lack of money. That's about how we organise services. We would regard the atomisation of services due to so-called functionalisation of services, where you have many, many specialist teams, as having been a major problem that creates multiple interfaces that can reject people and that can lead to badly co-ordinated care.

Thanks, Dr Poole. I was going to say I did invite you all to speak, but if you feel that Dr Poole has addressed it and you agree with what he said, then, by all means, do so. But, if you want to add to it or disagree with anything even—. Dr Daffin.

Do you mind if I add to it? Thank you.

Absolutely. Please do.

I agree with what Rob has said already; I just wanted to add to it. So, we would see this as about addressing the social determinants of mental health, and not forgetting those when we talk about the social determinants of health, making a special place to remember that our mental health is not separate from our health. So, when we're having those conversations, to really include the conversation around mental health and mental illness in that.

But when we're talking about addressing the social determinants of mental health, this doesn't just mean building good housing, safe and secure places for people to live, or access to education or having enough money; it's also about our relational needs too. So, it's about having safe and supportive relationships with our families, our friends, our communities and ourselves. It's about having those basics of being able to access security, meaning, purpose and trust, as well as having access to the physical things. And it's important that, when we're discussing the social determinants of health, we don't forget those relational parts as well.

So, this, for us, means creating communities that are safe and inclusive for everyone to live in, whatever diversity or difference that you have. So, when we're thinking about, 'Are we doing this well?' everybody should be able to feel, 'I belong here.' It's that kind of cultural shift that we're looking to achieve, because the opposite of having traumatised communities, or communities that are in distress, is psychosocially healthy communities. So, in order to address this problem, if we're understanding mental health is largely determined by our circumstances, we need to be thinking about how do we create psychosocially healthy communities, psychosocially healthy places to live. What that means is creating spaces where people feel that they have agency, security, connection, meaning and trust. And it means moving away from what Rob's already said about circumstances and systems that perpetuate fear and control over people. So, it's creating those opportunities for people to thrive.

Often when we talk about mental health, we say that one in four of us will get a mental health problem. But the thing that that disguises for us is that it's not randomly distributed and it's not just about the fate of our biology or a lack of personal resilience—that's not true. What we're seeing is correlated to, well-documented to our circumstances. Therefore, this is less about 'who' and it's less about targeted groups, although particular groups will experience more injustice, and it's more about creating the right circumstances for everybody to thrive, for everybody to feel that they can belong to, in order that we can then address the mental health inequity. And in order to do that, we need to be focusing on eradicating circumstances that cause prolonged exposure to things like toxic distress, which we know are associated with adverse childhood experiences, but they're also associated with adverse community and public health experiences as well.

Thank you, Dr Daffin. Ewan Hilton, don't feel obliged to come in, but by all means if you want to add to what's been said.

I agree completely. I completely agree with all of that, particularly what Jen was speaking to there, around the importance of community and relationships. And you took the words out of my mouth about the one-in-four narrative; I think there is something really unhelpful about that narrative. And there's a public narrative around mental health that needs to shift and embrace the social determinants of mental health and the fact that we are more likely to experience this if we've had a tough time.

And just a point on the budget really: I think the mental health budget is one of the biggest spends in the health budget, and we keep throwing more at it. Increasingly, we are seeing this as failure demand, and it will continue to be in failure demand and increasing demand until we address the social determinants of mental health that help to prevent people from needing the level of service that their current demand is showing.

Thank you. Jack Sargeant, you want to come in.

Yes, thanks, Chair. Just very quickly, just picking up on Ewan's point there, and Dr Daffin's, on the one in four, I agree—I don't think it's the right terminology to use. Would you not agree it's four in four? We all have mental health and some people just have worse days than others, and actually perhaps the focus on prevention and the strategy for mental health should have that focus and that lead?

It's interesting that we're coming to the final year of the 10-year mental health strategy, 'Together for Mental Health', and it's under review at the moment. Our feeling at Platfform is that the new strategy needs to be built absolutely around addressing the social determinants of mental health, which includes services. But the situation will not change until we address the social determinants that are causing people to experience emotional distress. And it is four in four, but it's not evenly distributed. You're more likely to get sick, suffer, experience emotional distress, mental health problems, if you're living in poverty, if you're facing discrimination, hate crime, don't feel connected to your community or the people around you.

Dr Daffin, just briefly, because we've got quite a lot to get through, but then I'll come on to you, Professor Poole. Dr Daffin.

Just to reiterate, yes, I agree with that. So, what we need to understand is this is about a continuum, and if we put lots of stress on people and we overload them, then they're more likely to have these experiences, but we are all equally subject to them. The thing to take into account there is trans-generational trauma, so it may look like people are born then more vulnerable, I think we have to say, to mental health. But if we really understand that this is not about what's wrong with us but what's happened to us, we need to bring trans-generational circumstances—so, the epigenetics, the loading that people then carry—into the conversation as well. And then we can start to see where those hidden patterns of circumstances are hidden in our histories, as well as then in the present circumstances, which I think helps us understand that it's not one in four, it's four in four.

Thank you. Professor Poole.

I'll be brief. I just would like to say that I think the problem with the four-in-four argument is it overlooks the position of people with particular vulnerabilities, particularly people with long-term problems around psychosis, who are easily forgotten in an argument that says that this is simply about a continuum of distress. I agree there's a continuum of distress, but there is also something about people with long-term problems, with psychosis, that makes them particularly vulnerable.

Thanks, Professor Poole. I know that we've got a lot of questions to get through in the next hour or so. Please don't feel you all have to comment on every question, especially if you agree with what's being said. That'll allow us to get through all the questions that we're hoping to ask today. Gareth Davies.

Thank you very much, Chair, and good morning, everybody. Just to kick off on the first question, to what extent do you think there's an over-reliance on a medical model for mental health in Wales—and I know Professor Poole touched on it in his opening remarks about the use of prescriptions and medications—and what impact does that have on people's experience and outcomes?

So, I'm just looking—. Yes, Professor Poole did touch on that quite a bit in his opening comments. Dr Daffin or Ewan, do you want to add anything to that at all? Ewan.

Okay. Yes, I think the whole mental health system is constructed around the medical model still, and whilst that has some value and meaning for people and it's a gateway into help and other services—so not just mental health services, often housing, financial security benefits, and many, many other things—it is also limited, and I think too often, it locates the problem inside the individual and doesn't contextualise it in relation to the social determinants that we're talking about. But I think Jen can speak more eloquently on that than I probably can. So, I will defer to Jen.

Dr Daffin.

No pressure. [Laughter.] If we're understanding that mental health is also about our emotional regulation and that that dysregulation is caused by our circumstances, then we need to also go back and create the right circumstances for people, looking at when we're using medications. They are helpful ways to get people there, but long-term use hasn't shown to be helpful and has been shown to be harmful as well, and it doesn't do anything to help people change their circumstances so that they're not causing them problems. It's like a sticking plaster, so it's not going to the deep-rooted cause, it is just masking over the causes.

So, I can see Joyce wanting to come in with a quick question, and I'll come back to Gareth. Joyce.

It's a quick question, but I don't know about the answer. You talk about emotional regulation, Dr Daffin, but, of course, lots of people use other means to regulate their emotions, so substance misuse, alcohol misuse and all those things. So, there's a clear link—when you said those words, it was obvious to me that there's a clear link that if it's a medical model, people seek their own medication and also don't want to go to the GP or they can't get to see a GP. So, as I said, it's an easy question, no easy answer. So, how do you see the links with that? We know that there are problems, clearly, with over-prescription of medication anyway, because they of themselves can become addictive, but I just wanted to tease out the links between the difference of people emotionally regulating the way they feel.

Okay, thank you, Joyce. Dr Daffin.

So, what we're not then learning, or what we're not exploring, is what are the alternative ways to learn how to do emotional regulation. There's lots of literature on that. So, we talk about needing to be regulated in order to relate to others in order to do reflection and thinking, but often, when we talk about these, we go straight to therapies and things like that—we miss out that bottom layer of what regulation means and how we achieve that. Medication can be helpful in some situations, but there are a whole host of other ways that we could do that. Some of those we're seeing through the whole-schools approach. We're looking at the environment: how we create a balanced psychosocially healthy environment for people to be regulated. If we're looking at emotional distress, then how do we create the circumstances to co-regulate with each other, especially in young children, to teach young children how to do that, but then also how do we create the circumstances for adults to be able to do that? That's as much about our relationships with ourselves and others, as well as it is to our circumstances, and I think we jump that—we go straight to medication and we don't spend enough time thinking about how we can create that around us on a daily basis. Yoga is one example, but breath work has also got a good evidence base behind it. But there are many other ways that we can do that, just in connection with each other. Going out for walks—. There will be unique ways for individuals, because we all have our own unique ways of wanting to do that stuff as well—focusing a conversation around that.

Can I ask Gareth Davies to come in with his next question? Then I'll come to you, Professor Poole; I know you wanted to come in as well. But just to move things on, Gareth, if you want to ask your next question and then I'll come to Professor Poole.

Thanks again, Chair. Many people and stakeholders call for a trauma-informed approach across all of the public services. What does that actually mean in practice, and what action is needed to further develop this and implement it across Wales?

Professor Poole, if you want to address, perhaps, Joyce's question and Gareth's as well. Professor Poole.

Right, okay. The question about the medical model. Our view would be that the medical model—. If we abolish the medical model tomorrow, we're not necessarily going to do very much to achieve an improvement in people's mental health. That's the first thing. We must be focused in social terms on the things that make a difference once you've got a mental health problem. The medical model is a bit of a straw man. It is whatever people define it as. I would include public health, therapeutic communities and psychotherapy within the medical model; others would not take that view. It's certainly the case that we don't have sufficient psychotherapy resource available within the NHS in Wales. It's been extremely poor. Is psychotherapy part of the medical model? My view is that it is, as someone who has much training in psychotherapy.

The trauma-informed approach—trauma is unquestionably important in causing mental health problems. However, it is important we stick with the evidence, and there is good evidence that some people's problems are not associated with trauma. So, it isn't a one-size-fits-all approach. We need to understand that there are pervasive influences that cause people to develop mental health problems, and there are indeed biological problems that can cause people to develop mental health problems, not least, for example, from the effects of medication, sometimes.

The final point I wanted to make is about what sustains the medical model. We've got some unpublished research, which will be submitted for publication in the near future, not regarding antidepressants but regarding opioids for long-term pain, which is actually a problem that is associated with mental health difficulties in both directions. We've looked at what GPs say about their own prescribing, and they often are worried about their own prescribing but don't know what else to do. And I think that perspective about what drives a medication-driven approach to all kinds of problems needs to be understood as part of the systems that we have established, that we drive practitioners into following approaches that they know are not the most appropriate approaches, but are the only thing that they feel able to do.

Thank you, Dr Poole. Ewan Hilton.

Yes, I agree. Abolishing the medical model today would not help anyone at all. We have a system that's built on it. And I think people are using the word 'trauma' everywhere we go at the moment, and the risk is it becomes meaningless. So, I would draw your attention to the Wales trauma framework that is out for consultation at the moment, which was a collaboration between public health, the ACEs hub, and Traumatic Stress Wales, which is starting to try and describe what a trauma-informed public service in Wales would look like. We've been working hard alongside the team, helping to shape that. We feel that it offers enormous potential in helping to shift thinking in the system. What we don't want to happen is it just becoming another Welsh Government guidance document that everyone reads once or doesn't even read, and it sits on a shelf and doesn't need to change. So, for us, the focus has got to be on what that means in terms of implementation across the system. And moving from a mental health system that is over-reliant on a medical model to one that truly embraces the impact of trauma but also the social determinants of mental health is a 10 or 20 plus year project. I think the issue is we always look at the now and what's happening now, and we have short-term programmes of Government. I think what we need is cross-Government commitment to a long-term transformation project that commits to embracing a trauma-informed approach to understanding emotional distress and the impact of social determinants and build all public policy making and legislation development around those things. So, this is not a short-term fix, this is a long-term system change, cultural change, philosophical change project.

Gareth, do you have any final questions on this section, sorry?

Yes, just a quick final question on the details of concerns about the use of personality disorder as a diagnostic label. I know from my experience it is often used as a diagnostic label for people who present themselves as having bipolar disorder, and then personality disorder is something that's diagnosed if bipolar can't be diagnosed, if you know what I mean. So, what are the issues around that in terms of getting the right support for people and making sure people actually get the right support that they need and the right medication and help and a structure around them, in order that they're getting the right sort of package?

I'll start, but defer to people who know more of the technical detail. We have recently launched a campaign requesting a review into the use of these diagnoses in Wales. The indications are that it is often allocated to women more than men; it is seen as a diagnosis of last resort. The evidence around personality disorder diagnosis is that it's rooted in trauma, and there are alternative ways of understanding people who have experienced significant severe prolonged trauma. It often excludes people from services. So, overall we would say we would like it not to exist. We think it's unhelpful and we think there are other ways of seeing people, hearing people and responding to people who have experienced significant trauma. But I'll again probably pass to Jen.

What we're seeing is that 81 per cent of people that have received that diagnosis in the study reported a history of trauma, but what we don't see is a routine inquiry or a routine history-taking of trauma from mental health services, and if we did see that, then would we be giving that diagnosis, when what's actually perhaps been a problem, or what it masks—? I guess what personality disorder risks is the diagnostic overshadowing, then, of trauma and distress-related issues that then don't get the proper support that they need, and we know that there are really good protocols for complex post-traumatic stress disorder, there's really good intervention for trauma, but if we're labelling—. If we're not taking proper histories, then we may be missing those opportunities to provide the correct support to people. There's also research around the use of that term as a pejorative term for women, and so there is perhaps some reflection to do on why and when are we using this, and are using it in the correct way, and are we exploring and asking the right questions of everybody that's entering the system, so are we taking a routine trauma history?

Thank you, Dr Daffin. Mike Hedges, do you want to come in at this point? Mike.

Diolch, Cadeirydd. We have heard a strong link between antidepressant prescribing and poverty. We've heard that GPs feel they've got nothing else to offer people to manage their despair. But is it any surprise that people who are struggling to feed their children, who can't afford to heat their homes, who are worrying about their rent are suffering despair and have mental health problems? Is the mental health problem—? In my view, it is, so I'll ask you: is the mental health problem for a number of people being brought on by poverty and the conditions in which they live?

Professor Poole, you wanted to come in.

I'll answer that question first. Yes, that's an extremely good point. The fact about antidepressants—there are controversies about antidepressants. They're not a perfect fix, they have got some unpleasant adverse effects for some people—quite a large proportion of people—but they're very effective for severer forms of depression. What they're not effective for—and it's quite clear from the evidence—the kinds of depression that are responsive, simply responsive to very adverse circumstances. So, therefore, you give people antidepressants, and of course all you get is the side effects and no real benefit. But there are people who become more depressed and who do benefit from antidepressant treatment.

The—. Oh, gosh, I've forgotten what the other part was, and it felt really urgent to respond to it at the time.

Don't worry, we can come back to you, Professor Poole. Does anybody else want to come in? We'll come back on that third point, absolutely, Professor Poole. Dr Daffin.

On the point of poverty and mental health, there is a cause—. So, poverty is as much a cause as a consequence of mental health, and so you're right, Mike, that is what we're seeing. And so, why, when we know that these things are causing people distress, would we just look to medicate that and to hide that distress? What we're seeing is not a tsunami of mental illness, but a tsunami of distress. And so the long-term solution to this, to break intergenerational cycles of mental health problems, of trauma, of distress, of poverty, is to go upstream and figure out how do we break that cycle. For us, that's about an integrated, as Ewan said already, approach. So, you spoke about the limitations of the medical model. The medical model, whilst it may evolve and has evolved, is organised around a reductionist approach. And what we're seeing is that mental health is complex; it involves many different parts. We tend to think mind, body, soul, circumstances, for ease, but it involves many different functions, and so we need a holistic, genuinely integrated approach that can hold complexity rather than fragmenting and soloing the different parts out and viewing them in isolation.

And Professor Poole, you wanted to come back in there.

My memory has come back. We were talking about personality disorder. Okay, a categorical personality disorder is, unquestionably, a highly problematic way of looking at things. I think banning diagnosis is difficult. But, certainly, one has to understand personality problems in terms of developmental issues and, indeed, trauma, which is by far the commonest cause.

But the thing that really causes difficulty with the mental health services is that mental health services often feel driven to make very controlling responses to people who present in mental health crisis when they've got personality problems, which is exactly the wrong thing to do. And therefore we have to understand the imperatives that are placed upon the mental health professionals who deal with this to do things that are actually the wrong things to do. This isn't simply about people's understanding of disorders, if we want to call them disorders, but it's also about the consequences for not behaving in a particular way.

So, one of the things that we see is a combination of factors that mean that we increasingly constrain people to respond in controlling ways to avoid bad things happening, and then cause bad things to happen because of the types of responses they make. So, one of the things we think we need to do within services is to introduce a much greater, as Jen was saying, more history informed way of understanding what the right response to people's problems is, and not to have a knee-jerk reaction to issues that are real issues of risk that must be managed.

Thank you, Dr Poole. Did you want to come in with any further questions, Mike?

Just one very simple one: how do we compare in prescribing with countries like in Scandinavia?

Dr Daffin, you wanted to come in, and perhaps you'll address that last point as well.

That's not a point that I would be able to cover, sorry.

No problem at all.

I couldn't give you the facts of prescribing rates, but I know that we have very high prescribing rates and that that's an issue for us. I wouldn't want to comment on how we compare, but I do know that there are statistics around recovery rates for what we call the developing world. The developing world apparently has a recovery rate of about 60 per cent. The western world has a recovery rate of about 30 per cent. Given that we put more resource in, we have more money to spend, we've spent more time doing research, how come we're not getting the same recovery rates? Is that about the approaches that we're taking?

Dr Poole, it looks like you may have the answer to Mike's question.

Okay. So, the—. Well, I just wanted to tackle the recovering [Correction: 'developing'] world—. The low- and middle-income countries, the question of what recovery rates are is actually much more complex than that. And as someone who's spent the last four years doing work in south Asia, I can tell you that one of the problems is ascertaining who has got a mental health problem and what happens to them. So, I think we need to be careful about romanticising outcomes in low- and middle-income countries.

The question of international differences in prescribing—. America has got extremely high levels of prescribing. There's a variety of levels of prescribing across the world. By and large, across the world, prescribing is on the high side.FootnoteLink But, at the end of the day, we would see prescribing as a phenomenon that's arising out of inequalities and inappropriate services. Simply trying to get people to stop prescribing without actually addressing some of the things that drive it—. This is about inequalities, it's not about our models of services, although there are major problems with our models of services.

Thank you, Professor Poole. Joyce, do you want to come in at this point? Thank you.

We've spoken about barriers this morning, but there are barriers, sometimes, for specific groups, and those groups are people with, quote, 'co-occurring conditions', and the challenges that they face. I've mentioned substance misuse, but there are neurodiverse conditions and also dementia. Are you able to give or shed any light on addressing the barriers for those specific groups of people that I've just mentioned?

Again, we might not have time to bring everyone in, just in order to get through all our questions, but who would like to take Joyce's question? Professor Poole.

Yes, we would agree that people with substance misuse problems are excluded. Quite a large proportion of people with psychosis have got a substance misuse problem as well—it's probably about 50 per cent of everyone—and if it's used as a criterion for excluding people from services, it's really very destructive: people can be bounced between services and not really get a service in the end.

I mentioned earlier that we believe that there's a serious problem with atomisation of services. We need to have services that address people's problems and don't address individual diagnoses. So, we need to start with a focus on the person and their problem. Quite often, if you have a system that passes people from one bit of the system to another, it looks nice on a bit of paper, but every arrow on that bit of paper involves a change of team, a loss of information—all kinds of problems. We need to have a better model of addressing people's problems than the one we've got at the moment.

Thank you.

Sorry, Joyce. Dr Daffin wanted to come in as well.

Thanks for that. Sorry. What I think we need to be doing is—. There is so much overlap, why is there that overlap and what's underneath that overlap? So, are we looking, like you said earlier, at coping strategies that people use and people adopt and what are they doing that for? Is it about nervous system dysregulation, emotional regulation? And so, if we reframe the problem and look at, 'Is that what's going on with people here and they're just finding different ways of doing that?', then we need to organise our systems around that, rather than siloing and looking at the individual problems, like substance misuse versus self-harm, for example, as two separate things, and find a more unified way of looking at things.

There is another barrier, and that's those people who don't recognise that they have a mental health illness and therefore don't present at all. And I don't know if any of you can shed any light on those different groups that—and I hate this label—would be deemed to be 'hard to reach'. We would welcome any comments that you have about helping those individuals who don't even, perhaps, recognise that they need help in the first place.

I can just stand alongside you in my hate for that term and many, many other terms that we use to describe people in distress. So, I think it's about our own organisations' and systems' cultures. Who is hard to reach? Actually, we're probably the hard-to-reach people, not the people who aren't reaching us. So, I think it talks more about system culture and workforce, and it's really easy to point your finger at services and say that they're not doing what's needed, but, actually, it's a scary, hard place to work. So, when we talk about what a trauma-informed public sector looks like, it's not just about a trauma-informed service, it's a trauma-informed workplace, where people feel safe to do what they think is right. Our services need to stand alongside people and with people, without needing to label them as 'hard to reach' or 'dual diagnosis'. It's about a human relationship with another human that hopefully leads to something better happening for that person in their life—community-embedded responses. There's a lot wrong with the way our systems are structured and managed that prevents good people from doing good work and getting to the places and people that we need to get to at the moment, I think.

There's just one area, Chair—I'm going to use a little extra time—that was briefly passed over, really, because of time, and that was the lived experience, and particularly domestic abuse with children, and if any of you have anything that you can share with us about the services recognising the mental health stresses on children that will live with them through a lifetime as a consequence of domestic abuse.

Dr Daffin first, and then Professor Poole. Dr Daffin.

Sorry, if I've understood correctly—. So, yes, that's noted as an adverse childhood experience. But what we'd say, linking back to what Ewan was saying, is that it's about coming alongside people. If we're talking about understanding the trauma and the dysregulation that happens to people, then we need to understand that they may not be able to relate, and so clinic-based models that you have to go to are probably too much. That's asking too much of people who are in quite distressed situations. And it's about coming alongside them—so, coming alongside where they have existing relationships. That's the same in those services as well. But when we're coming alongside people, we need to come alongside them in a whole-family way, recognising that there are inter-relational dynamics that will occur, not just for the adult, but between the child and whoever else is in that family group. And so, rather than thinking about this as just an adult problem, we need to think about it as a whole-family problem, and then organise our intervention or our support around that, taking into account what might be happening for the child as much as what is happening for the adult, and that they are interactive.

Professor Poole.

I would support that and just emphasise the importance of domestic violence—specific resource for domestic violence—because it represents, often, an emergency and can lead to homicide. To go back to the issue about hard-to-reach groups, I think we have to follow the evidence, and there is quite good evidence about how you reach what hard-to-reach groups are. I worked for 16 years of my life in Toxteth, in Liverpool, as an NHS consultant, with a population who were allegedly hard to reach. They weren't hard to reach. If you went out and spoke to community groups, formed relationships, formed continuous relationships between the teams, employed more local people from the local community within your service, listened to what people said, provided services that were close to where they were, then, actually, people became much less hard to reach. If you started working with people in their home, and, as Jen said, not clinic-based, but actually going to people in their own space, which often was less threatening to people and less alienating—. Spend some time to engage people, then you can reach quite a high proportion of people who are otherwise regarded as hard to reach and end up [Correction: 'and who often end up'] being subject to legal powers. You can quite often get people to accept help without recourse to legal powers if you work with the community and with them.

One of the most destructive things we have at the moment is what I would regard as a production-line approach to mental health that says we assess, we intervene and we discharge. But, more than anything, good mental health services are about forming relationships with populations that are long term and building trust, and, if you don't do that, it is always going to fail.

Thank you.

Dr Daffin, you wanted to come back in, I think.

Just to add that we have an example of that in Wales. The child and family psychology team in Aneurin Bevan health board is doing some great work with the Families First services, where you're integrating that whole family, poverty-orientated approach with psychosocial support. That would be a good model to explore more.

Joyce, do you have any final questions? We're a bit stretched for time. Or have you asked everything you wanted to ask?

No, I'm fine, thank you.

Thank you, Joyce. Jack Sargeant.

Diolch, Cadeirydd. My first question was going to be around community solutions and the role of different partners and the role of communities, but I think that Professor Poole has answered that in good detail, and Dr Daffin then has given us an example. Perhaps I could ask witnesses, because I'm conscious of time, if there are further examples of where we should be looking, perhaps they could send a note to us after the committee meeting where we could see that. So, I'll move on, Chair, because of time.

We've heard from both the Centre for Mental Health and the Mental Health Foundation. Both of those organisations highlighted the benefits of social prescribing, so perhaps I could get your views, maybe each of the witnesses, as briefly as possible, on the potential for further development of social prescribing schemes. Dr Daffin.

I think it's a good approach that is showing good evidence. I'm not familiar with it in that level of detail, but as a theoretical concept, if it's still used in a reductionist way where we're not thinking about the person in a context and handing over power to them, we're just then telling them to go here or telling them to go there, then we're going to miss the broader benefit of that. I think there's some great work in Swansea, where they're putting workers into the community. I would really love to see that embedded in that approach as well.

Thank you. Professor Poole.

Social prescribing at least acknowledges the importance of the social. We have concerns about the need to have a mental health label for access to social facilities to be prescribed. It's quite disempowering. We would regard access to social facilities and social opportunities to be really important, and we've talked in our written evidence about proportionate universalism. There are some specific social interventions that are known to be helpful to people with severe mental health problems, including individual placement support in employment. There's a good evidence base for that. There's good evidence around supported housing. But if we can only access social facilities by them being prescribed, we haven't really solved any problems.

Thank you for that. Ewan, any further comments?

No, nothing to add.

Thank you, Chair. Thank you to the witnesses as well.

Thank you, all. I hope you can hear me, my connection is a little bit unstable. Have you asked all your questions, Jack? Yes. Lovely. Thank you. If I come to Rhun ap Iorwerth next, and if my connection is a bit unstable, then please indicate to Rhun, who can chair that section of the meeting. Rhun.

Diolch yn fawr iawn, Cadeirydd. Bore da ichi. Ychydig o gwestiynau, mae amser yn dynn. Yn gyntaf, ynglŷn â ble rydyn ni'n targedu ein hymdrechion, rydyn ni wedi clywed yn barod heddiw a droeon o'r blaen mai'r rhai mwyaf bregus a'r rhai mwyaf agored i broblemau iechyd meddwl sydd yn cael mwyaf o drafferth cael cefnogaeth. Rydyn ni hefyd wedi clywed cyfeiriad at y ffaith bod pawb yn gallu bod yn agored i broblem efo'u llesiant. Ble mae cael y balans yna rhwng targedu poblogaeth gyfan efo negeseuon pwysig ar iechyd meddwl a thargedu'r rheini sydd mwyaf peryg o wynebu problemau iechyd meddwl eu hunain? Proffesor Poole yn gyntaf, efallai.

There are certainly some groups that need to be specifically regarded as at risk, and we must follow the evidence. The evidence base is not perfect. There are some important things that we don't have clear evidence on, but we've got some suggestive evidence around. So, for example, one of the things that seem really important to people's mental health is financial strain. We have very poor access to advice services these days. As you know, the entire third sector has been drained of resources during austerity, and we would argue that one of the most important things to provide to people within mental health settings is access to advice on housing, on debt and so on and so forth.

The other thing that is often neglected, but has a big impact—we've got work about this—is the withdrawal of legal aid from people who are facing problems within the civil justice system, people who have got housing problems, who come to the county court, find themselves unrepresented in court and then having no way of finding their way through the system. Those support and advice services don't solve a structural problem, but in the short run, they are something that can be targeted and can make a difference, which is why I made the comment about the devolution of the Department for Work and Pensions. So, I think we need to think about things in terms of what are the things we can do in the short run that can make a difference in the here and now, without neglecting the longer term inequalities that need to be addressed as a strategic issue.

Mae'r rhain yn bwyntiau rydych chi wedi'u gwneud yn dda iawn. Ewan Hilton.

Sorry for interrupting you. I would agree with that, but it isn't just the third sector that's been decimated financially—so have local authorities. Local authorities are our communities, and where community stuff and prevention should happen, and they are on the bones of their backsides, too. This takes me back to this is a long-term project. 'Prevention' is the word. We've got great legislation, great policy, we have the future gens commissioner, but 'prevention' is just a word for too many people, it isn't actually there. This takes me back to it has to be funded. It is no use having two-year transformation pots of money that actually, basically, go into local authorities or health boards to fill holes in current services. This is back to the 10, 20-year cross-government, long-term commitment to a project to actually transform our systems so that they work in line with the rhetoric that we're so proud of in Wales that is enshrined in our policy and legislation. It feels too much just like words.

Diolch. Dr Daffin, pan fydd adnoddau yn brin—ac rydym ni wedi clywed yn fanna, mae adnoddau wedi bod yn brin—mae yna fwy o reswm fyth wedyn i roi ffocws clir i lle rydym ni'n defnyddio'r adnoddau hynny. Ydy'r balans wedi bod yn iawn, felly, yn targedu y grwpiau sydd fwyaf angen eu targedu, tra ar yr un pryd, o bosib, yn cadw llygad ar yr angen i roi negeseuon allan i'r boblogaeth gyfan?

I think we don't have a good public mental health understanding anyway, so there's room for improvement there. If we improved our public relational and emotional health understanding, we'd see gains there as well. We don't have that in Wales anyway, so there's work to be done there.

Councils are moving towards place-based approaches. So, we said earlier that this is less about the 'who' and more about creating the circumstances. Councils are seeing that, local authorities are seeing that and organising things at a place-based level. I'd say that is true for mental health as well. Place-based community development that's trauma informed is one way of organising scarce resource. We know those communities that are more deprived are correlated to higher rates of everything, pretty much, for simplicity. Why not target them, then, to break that cycle and put extra resource there? We know they'll need extra resource to heal and to create the right circumstances that they need, so why not target those alongside a more informed public health narrative as well?

We talk about people and groups who are more vulnerable because of, largely, socioeconomic factors. What about groups that are vulnerable due to particular moments in their lives? I'm thinking of perinatal mental health, mental health for young mothers or parents. There has been talk of perinatal mental health and the need for investment there. Are there particular groups, points in lives, that are being missed, I wonder? Just a quick one if you do have some thoughts on that. Dr Daffin.

It is a lifespan approach, but yes, you're right, getting those circumstances right early on will set people up. Then, creating the ripple affect around them to make sure they've got support throughout life is important. But getting those whole-family approaches right early on is really crucial. The evidence base does sit around that.

Professor Poole or Ewan Hilton, on specific points in life? If there's nothing in particular, I'll move—

Those two months—. Sorry. The first two months—

No, carry on, Dr Daffin. I'll come to Professor Poole after.

Just to say that there is evidence around the first two months, but it's an emerging area. So, that perinatal period is really important.

Yes. Professor Poole.

I completely agree. There are all kinds of vulnerable points across the entire lifecycle—right from birth to death—and that's just how it is. There are all kinds of groups of people who are neglected. We very rarely hear about Travellers' mental health, for example, and, actually, there is evidence of major problems within Travelling communities. So, I think there are all kinds of groups, but it does illustrate the difficulty of thinking about things in this atomised way. There's a broad equality agenda here.

This next question from me is just to invite some thoughts of yours, really, because we can't possibly do justice to the topic—it's about workforce. So, just maybe an overarching message from the three of you on the capacity of the specialist mental health workforce, but also the wider workforce in health and care, to deal with and respond to all those different needs in terms of mental health and well-being. Do you have some overarching comments, Ewan?

I'll be very, very quick and we can send you a report, and it's to do with some work we did during lockdown. We saw wonderful things happening in the system during lockdown, and we saw bad things happening, and we wanted to understand why. It came down to the culture within which people were working, not just the resource. It's about power, culture and leadership and values, and psychological safety in the work that we are all trying to do. I will get the report sent over to you so you can have a read.

We appreciate that, thank you very much. Dr Daffin, where do you begin on the capacity of the workforce, really?

Exactly. Everything we've said applies to the workforce. We're not separate beings. Everything we've said in terms of what creates the right conditions applies to all of our systems, including those that we work in. Those that work with distress and trauma and mental health challenges have a particular exposure, and so we should also give particular attention to that as well, and ensure that we're not retraumatising our workforce. Traumatised systems traumatise, and we know we've got lots of problems with resourcing and things within the NHS, but also local authority and our public systems generally. They're historically built on command and control, fear-driven approaches as well, so there are some real entrenched cultural issues to deal with as well to move to psychosocially healthy.

Thank you. And Professor Poole.

I completely agree. We need to create a working environment that is positive for the workforce's mental health, because we see quite a large number of people leaving employment within our mental health services whose mental health has been damaged by various things that have happened to them—and I don't mean things that have been inflicted by the service users in any way, I mean by the system. We need to create a working environment that releases people's skills and allows them to use therapeutic relationships in an appropriate way, which is very difficult for many staff in the systems that we've built.

And it's also about making sure that the skills are there within that really wider workforce—teachers, for example—to deal with mental health issues. Dr Daffin on that.

I was just going to say it's about really understanding what relational health is, and then applying that to practice, and allowing our systems to be able to accommodate for that. So, not being reductionist and process-driven about results, and things like that, but making it about relationships, and putting those at the fore and front. That's a massive mindset and cultural shift.

Okay. Thank you, all. We could go on and on on that.

Thank you, Rhun. Gareth Davies.

Thank you, Chair. Just to kick off on the Welsh Government's strategy and take the direction in that way, the extent, I think, to which we need to address mental health inequalities is getting quite recognised now across Wales, and also the UK Government. What's the benefit of a 'mental health in all policies' approach? I suppose we could ask the question as well, is it appropriate for the benefits of mental health in all policies to be there? What specific policies do you think need to be incorporated, and indeed, which policies shouldn't it be in, if it's not deemed to be necessary?

Can I go first and be very quick? Because I'm the only one in the office, and someone's knocking on the door, and I need to let them in. I would say that's what the current Government strategy has got, but it's still failure demand—it's like more housing, more services, more this and that, and it's not addressing the social determinant. So I would actually say that what we want to see is addressing the social determinants of health and mental health running across all Welsh Government policy and legislation, not necessarily just mental health and responses to poor mental health. That's my short answer. And I'm going to quickly just run to answer the door.

You go ahead and answer the door. No problem at all. Who else wants to come in? Dr Daffin.

For me, it would be about understanding what is that—so, what do we mean by 'mental health' and is that the right term to use, is that the right framing to give to this? If it's about creating the right circumstances maybe we need to name what some of that is and use that to inform policy and ensure that policy and practice are organised around that. So, for example, what's going to create psychosocial healthy conditions: agency, security, connection meaning and trust, for example, and making systems relational and valuing relationships. If we embedded those across everything, it would be different to thinking about mental health. So, maybe there's some more exploration around what exactly is it that we need that's going to reduce the burden of distress on us that we often talk about as mental health.

Professor Poole.

From my point of view, the danger is paying lip service in every policy and it just becomes an incantation, rather than action. The key issue here is that equality and social justice are public health issues, and everything that improves equality and addresses social justice is going to have an impact on physical and mental health, and that's the important thing for the Welsh Government. The really important thing for the Welsh Government is that we have got, for various reasons, a high level of inequality in Wales. And one appreciates how difficult it is, given the actions of the Westminster Government, but nonetheless it is those policies that increase social justice that will make a difference in the long run, rather than simply saying, 'We're mental health positive', which becomes one of those things you put on your letterhead and doesn't necessarily affect anything.

Okay. I appreciate those answers. Thank you very much. I know we're tight for time, so I'll keep my next question short and just ask what metric we should use to measure action to improve mental health and reduce inequalities in Wales. How do we measure that and how do we know where we've had success and where the Welsh Government, indeed, needs to improve and enhance those policy areas further?

I think it's really easy to jump to how an individual feels—'Do you feel the service worked? Are you feeling happier or more hopeful for the future?'—and there's some value in that. We're only just getting a mental health data set in Wales, but the issue is that it's still quite individualised. We need to be, I think, measuring really big, whole-country stuff to see if our strategies and approaches to addressing inequality and addressing poverty are working, and then we should see decreased demand on services. So, rather than focusing on individual outcomes all of the time, I think we need some bigger indicators that help us understand whether the bigger actions we're taking about addressing those big, knotty issues are really truly impacting on people's mental health and physical health.

Are there any other answers that anyone would like to give?

After you, Rob.

Thank you very much. It's actually surprisingly difficult to measure the impact of services, but it isn't so difficult to measure the impact of social factors. I'd suggest two things that would be important indicators. The first is the suicide rate. Suicide rates are affected by the economy and they're directly affected by major social changes. And although suicide is not simply about mental illness by any manner of means, by definition it is about mental health. So, I think if we could see some shifts, not necessarily compared with the rest of the United Kingdom, but in a secular trend in Wales, that is a reasonably sensitive measure of how Government policies are impacting overall. There are major differences in suicide rates between different countries in the world—very big differences, like five-fold differences.

The second thing is, in terms of our services and what happens to people with identified mental health problems, we should measure social outcomes. Social outcomes are much more important to people than clinical outcomes. We know that. There's an evidence base around that. People are concerned about how they live their lives. And if we put greater emphasis on how people live, then we're going to get a much better measure of how we're doing.

Thank you. And Dr Daffin.

I agree with what Rob said. It's complex, and to suggest that we can influence and have control over everything in complexity, it's not possible, but it's important to have some key markers. So, just holding alongside that—the difficulty there is in measuring, because we're talking about the negative end of that—the positive ends, how do we measure that people are thriving? It's a really complex task. It's a really difficult task. Some of the measures and some of the ways that people are exploring at the moment are story-telling, and using those methods for evaluation but also for social change, and employing measures that can hold more complexity and can help us understand what's the story of what's going on here. We need those alongside, and we definitely need those not just at the individual level. Like Ewan was saying, they need to be broader stories that we're telling, because it's just really hard to say, 'This attributes directly to this', and because of the breadth of—. The social determinants are varied; they are very varied. There is a lot of stuff going on to consider.

Thank you.

Thank you, all. This is a final question from me. At the end of this piece of work, we'll be producing a report ourselves as a committee, making recommendations to the Welsh Government. I suppose I'm just asking you, really, all in bullet-point form, to tell us what you think the key priorities are for us to consider, and to tell us, in your view, what the priority recommendations are that you think we should be making to the Welsh Government. So, I'm asking you, in bullet-point form, to help conclude the meeting. Ewan, I think you indicated there.

I was scratching my beard. I'll go first.

You can go first for scratching your nose, then.

I think the social determinants for health, social determinants for mental health are core to all public policy in Wales. Cross-Government commitment to that is what's going to make a difference, and a commitment to this as a 10, 20-year project; it is not a short-term fix.

Okay, thank you, Ewan. Dr Daffin, key priorities for us as a committee, key recommendations you think we might like to consider making to the Welsh Government.

Improving public relational and emotional health understanding as a public health response; extending the whole-schools approach to a whole-communities approach; and change starts with self. We need to ensure that we're embedding these principles in our politics and our way of doing policy in this forum as much as we do in the other forums as well—so, putting that at the heart of everything we do here as well.

Okay, and just before I come to Professor Poole, if there are any other Members who have got anything pressing—a very brief last question—then we'll consider that as well. Professor Poole.

Bullet points: No. 1, prevention. Prevention is possible. You don't need to have a massive, complete elimination of mental health problems; a few percentage point reductions in rates makes a big difference. Prevention. No. 2, evidence—that we should follow evidence and where the evidence is inadequate, we should gather new evidence, and I mean evidence in a broad way. We need empirical, quantitative evidence. We also need qualitative evidence. No. 3, access. People should be able to access help when they need it, not after some long delay. No. 4, that we measure social outcomes. I've made that point already—that a measure of success should be social outcomes. And finally is that whatever help we offer people should be founded upon relationships with communities and with individuals.

Thank you very much, Professor Poole, and thank you, all, for being succinct in those final messages; we really appreciate that. Any other Members have any final, pressing questions? No, I don't think so. Thank you. In that case, can I thank you all very much for your time today? It's very much appreciated, and your written evidence that you've provided to us ahead of the meeting. So, thanks ever so much. We'll send you a transcript of proceedings from today. If you want to add to anything, then please do if you think it'll be helpful for our work. But, diolch yn fawr iawn. Thank you very much for being with us today. We're going to move on with the meeting now, but by all means leave as you feel appropriate. So, thanks very much.

Thank you very much.

Thank you very much.

Thank you, all.