UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 95 v
HOUSE OF LORDS
House of COMMONS
MINUTES OF EVIDENCE
JOINT COMMITTEE ON THE DRAFT MENTAL HEALTH BILL
Wednesday 15 December 2004
MS JANE HUTT AM
MR DAVID MELDING AM, MS KIRSTY WILLIAMS AM
and MR RHODRI GLYN THOMAS
MS MAG RICHARDS and MS CELIA COWIE
MR PRYS DAVIES and MR ANDREW WHITE
Evidence heard in Public Questions 529-632
USE OF THE TRANSCRIPT
Taken before the Joint Committee on the Draft Mental Health Bill
on Wednesday 15 December 2004
Memorandum submitted by Jane Hutt AM
Examination of Witnesses
Witness: Ms Jane Hutt, Assembly Member, Minister for Health and Social Services, Welsh Assembly Government, examined
Q529 Chairman: Ladies and gentlemen, before we formally start this session I would like to thank our hosts at the National Assembly for their help in organising this meeting; this meeting is a procedural first. Never before has a joint committee of the House of Commons and the House of Lords taken formal evidence in the Welsh Assembly. We are into our third month of oral evidence hearings in Westminster on the draft Mental Health Bill; in the course of those hearings we have heard from many Welsh stakeholders alongside their English counterparts, we have also received numerous written submissions from Welsh stakeholders and today we are very much looking forward to exploring more deeply the Welsh views on the draft Mental Health Bill. Can I start by giving a very particular welcome to Jane Hutt, a member of the Assembly, who is the Minister for Health and Social Services in the Welsh Assembly Government? As you are the first witness, Minister, can I start as I am going to with every witness by reminding everyone that this is a public evidence session; a transcript in English will be produced and will be available on the internet after about one week. It will be open for textual but not substantive correction. Can I also say to all witnesses who are waiting, please speak into the microphones and speak up when you come to give evidence so that we can hear every word, though I must say this is a better committee setting than we usually use because the room we usually use is very much larger than this. Thank you very much for coming; did you want to make any opening remarks or can we move straight into questions?
Ms Hutt: Thank you very much indeed, Lord Carlile. (Through the interpreter): Thank you very much for your invitation, I am very pleased to be here with you this morning. (In English): Welcome, and thank you very much for your invitation. Also, I am delighted that, as you say, this is a procedural first, it is a point of history in our devolution that you have come here to take evidence; I very much welcome and thank you for coming to Wales to hear evidence. In fact, both the Chair, David Melding, who is giving evidence, and myself as Minister wrote to you and asked whether you could come to Wales because of the extensive interest in rigorous scrutiny which you are undertaking through the pre-legislative route of this very important draft Bill. Of course, it is a very important piece of legislation, there is a need to update the Act but given that we are responsible in Wales for the delivery of health and social care and, indeed, for other aspects of policy such as housing which has a bearing on people with mental health needs and problems, and given that the Bill relates to compulsion and a very vulnerable group of people, I am very pleased that you are giving this scrutiny and coming to Wales to hear our views. Thank you.
Q530 Chairman: The regulations and the codes of practice under the draft Bill, as you know, have yet to be published, but one of the clearest things about this draft Bill is the reality of devolution. Could you indicate to the Committee which principles you consider should be adhered to when the National Assembly for Wales drafts secondary legislation, and in which areas (if any) would you expect the Assembly to exercise its discretion to make regulations which differ significantly from arrangements in England?
Ms Hutt: Thank you very much. I think the issues relating to the principles are very important and of course they have been laid down in general in terms of the three points of involving the patient in decision-making and through decision-making ensure that they are open and fair decisions, and also that intervention is on the basis of least restriction. I envisage that these will be adhered to in our approach to secondary legislation, but of course we need to underpin this by Welsh needs and circumstances and indeed the Welsh policy framework. That rests within our Adult Mental Health Strategy and indeed our Adult Mental Health National Service Framework; just to mention the Adult Mental Health Strategy, that was published in 2001 and the title of that strategy was Empowerment, Equity, Effectiveness and Efficiency, and those are the principles which we would want to underpin secondary legislation, particularly looking at the issue of empowerment, empowering our service users and their carers. We also, as you know, have a statutory obligation to promoting equality of opportunity in the Government of Wales Act which is key, and we will obviously come on to issues around the equality of Welsh and English language and also the different structures in relation to health and social care. If I could just address your issue beyond that, in terms of those are principles that would underpin our secondary legislation, but if we look at issues where they may be variants or differences or where maybe we want to seek the opportunity for differences and variants, what I would say at the outset is that we would like as much as possible to be left for secondary legislation. Because we are responsible for health and social care and we have underpinning the National Service Framework and strategies, we do want to ensure that as much as possible is left for our discretion in relation to secondary legislation. If we look at the concerns of stakeholders - and you have had many responses, I appreciate, as well as my own written response in terms of Welsh needs and circumstances - we would want to consult widely, as we are intending to do in relation to the development of a code of practice and secondary legislation. We already have an Implementation Advisory Group for our National Service Framework which is co-chaired by a user and indeed someone from the voluntary sector in mental health who are guiding us in our implementation, but I should perhaps just mention some of the hotspots if you like in terms of what is emerging, where a variation might emerge if we have the opportunity. For example, the issues around approved mental health professionals - and again we have had a great amount of evidence regarding this - we feel that clearly the responsibility will be with the local authority in terms of approving the mental health professionals and there are issues around the approved social worker role, so we would want the opportunity to have the ability and freedom within Wales to look at that very carefully and to provide directions relating to the approved mental health professionals, recognising that there are concerns, if this does extend in relation to CPNs and other health professionals, relating to independence in the examination process. We also recognise that there are issues around the opportunities for multi-disciplinary working in terms of the opportunities for clinical staff as well as those of the social work profession. We would also want to be looking at who could be, in addition to psychiatrists, clinical supervisors. Those are areas which have been raised with us, but I think the major issue and concern does relate around the impact and use of compulsion, and we do feel, as I said in my written submission, we are in favour of exclusions, and you will know that I have referred to the Scottish legislation in this respect, but in terms of the use of compulsion what I want to seek as Minister is as much flexibility through secondary legislation for areas in the Bill that affect both the rates and the use of compulsion in Wales.
Q531 Chairman: Forgive me for interrupting you, would that include the use of Community Treatment Orders; and perhaps you would indicate in the context of the answer you have been giving, given the widely divergent evidence this Committee has had about even whether there should be Community Treatment Orders, let alone what they should be, what categories of people with mental illness would you like the National Assembly to define as suitable for Community Treatment Orders?
Ms Hutt: We would seek regulatory power through our secondary legislation for that very issue. You are receiving evidence about this in terms of should there be that route in terms of non-residential; we obviously recognise that there is an issue around the revolving door type of patient and concerns as far as that is concerned, but we would certainly want to have the opportunity in terms of secondary legislation, to consult widely as to how we would deliver on that regulation.
Chairman: Thank you. Mr Hinchliffe.
Q532 Mr Hinchliffe: I wanted, Minister, to pick up your point about the approved social worker role. I personally broadly agree with what you are saying, but one argument against what you are saying and in favour of the way the Bill suggests we should go is that increasingly we will see a much closer working relationship between health and social care and the possibility that certain roles like CPN and social worker may get much closer together. Do you not see that 10 or 20 years down the line we may have a very different professional person in front line mental health than those we have now?
Ms Hutt: Yes, and I think that is where the approach to workforce redesign is crucial, and I am sure we will go on to that in response to further questions, because we are modernising and it is a key action in our National Service Framework to modernise and redefine the workforce; indeed, in Wales we have chosen to have health and social care closely linked. Our local health boards are co-terminus with our unitary authorities for health and social care and we have health, social care and well-being strategies under statute that the partners have to develop, so I can see the progression in terms of that direction. I think it is the issue relating to independence and the role that obviously you are teasing out in relation to the approved social worker, and I think that through secondary legislation we have the opportunity to actually consult more widely. I do not think this is something we should be rushing to, we want the flexibility within the Bill to really root and branch scrutinise what that could achieve, recognising the concerns about independence, the concerns about the role and the opportunities as you say, David, that this could produce.
Chairman: Mr Williams.
Q533 Hywel Williams: (Through the interpreter): Thank you very much, Lord Chair, and good morning, Minister. I wanted to raise a specific matter with you regarding Community Treatment Orders. I have a concern about rural areas in Wales where it will be more difficult to implement these; would you see these being implemented differently in Wales compared, for example, with urban areas in England where there are actually no resources so there will be inequality or inequity in terms of the choices of treatment available to people in rural Wales?
Ms Hutt: Again, it does go back to those key principles of empowerment, equity, effectiveness and efficiency and, indeed, in terms of our obligations in the Welsh Assembly Government to equality and promoting equality of opportunity, and recognising in terms of equity that that is where our National Service Framework and the implementation of it is key in order for us to be able to have appropriate services for people in rural areas. I know this is something we will move onto in terms of implementation of our National Service Framework and the Care Programme Approach, but it is clear that the rurality of Wales as well as the language issues will have to be taken into account if we are to deliver on that.
Chairman: Mrs Blackman.
Q534 Mrs Blackman: If I could just push you a little bit more about the answer you gave to Lord Carlile about Community Treatment Orders, why are you so much more positive about the use of Community Treatment Orders? A lot of the evidence we have taken is either completely opposed or certainly extremely sceptical; why are you so convinced that they have a place and they will meet your key principles?
Ms Hutt: I think what I was being positive about was the opportunity to actually influence it through secondary legislation. We are concerned about Community Treatment Orders and indeed that has come back to us from our stakeholders; I apologise if I did not make it clear that what I was concerned about is that we have an influence, if they are to progress through the legislation and through the Bill, on how they should be implemented. Clearly, this is an issue where there are great concerns about equity and empowerment.
Q535 Mrs Blackman: Would you like to just elaborate a bit on the concerns that have been put forward?
Ms Hutt: It is concerns about, for example, the use of appropriate support and treatment, what is appropriate. That does come back to the issues which I touched on earlier about the compulsion and whether there are exclusions that can actually ensure that we have respect and recognition of what kind of treatment would be available, but I think it does go back to the concerns that have been raised with stakeholders. On the other hand, there is an issue around the fact that we do have people who potentially are losing out on treatment if they do not have the opportunities which, hopefully, the Bill will address, but it is a matter of concern from stakeholders and I am sure you have already had quite a few comments. The supervision is key and also the risks to patients in terms of increased use of compulsion, particularly in relation to Community Treatment Orders.
Q536 Chairman: On a day when two trains carrying members of this Committee to Cardiff happily arrived early, could you give us an estimated time of arrival of the Welsh code of practice and draft regulations, please?
Ms Hutt: Clearly, there are parts of it where we would have to be in tandem because we are already starting work in terms of mapping out the parameters of a Welsh code of practice and the direction of it, but I will have to work with my colleagues in the Health and Social Services Committee and the Assembly to deliver on the timetable for implementation. We are concerned about the timetable because we know that we want to consult widely, we want to deliver a Welsh code of practice and in terms of secondary legislation we will need to have time to consult. We already have processes in terms of open Government for full consultation and, indeed, in terms of a timescale for implementation we want to deliver on our National Service Framework to ensure that our services are robust, because there is a concern as you know, Lord Carlile, from stakeholders and indeed from the professionals and myself as Minister that unless we have our services fully in place and our workforce expanded, then we will have difficulties and there will be concern that there will be more use of compulsion than if we were really up to speed in terms of delivery of our services at the time of implementation. 2007/2009 is nearer than we think.
Q537 Chairman: I am sorry?
Ms Hutt: 2009 is nearer than we think.
Q538 Chairman: What, for the code of practice in draft and the draft regulations?
Ms Hutt: In terms of actually delivering we will have to deliver in terms of the Bill as it emerges.
Q539 Chairman: Can I be absolutely clear - I am not going to abandon a barrister's habit of a lifetime and indeed, Mr Lawlor, your official, knows my habit very well of occasionally asking quite specific questions - can we have a clear answer to the question when you expect to have draft regulations and a draft code of practice, and did you really mean to give the Committee the impression that it is 2009?
Ms Hutt: No, I apologise for the 2009. Ultimately, we will be ready for the commencement with our code of practice.
Q540 Chairman: So that could be a year and a half down the line.
Ms Hutt: Obviously, in terms of the timescale I understand we are talking about 2007, that is what the Department of Health has told us in terms of commencement.
Chairman: That is what they have told you. Mr Loughton.
Q541 Tim Loughton: On the draft code of practice can I just be sure about the mechanics of it all? We are told that we are not going to get the draft code of practice until the actual Bill is produced, whenever that may or may not be in the future. What input have you got into the Department of Health in London to influence that code of practice on the basis that you are saying that you are going to have to be all reactive or partly reactive to whatever is produced in London as to then producing your own version of that code of practice? How widely is the Department of Health consulting you proactively at this stage, or are you just waiting until you get what you are given and then will have to adapt it accordingly for your own Welsh version. How do you envisage this actually happening, because your timetable is going to be that much more squeezed if you are waiting on London?
Ms Hutt: We are certainly working in tandem with the Department of Health in terms of the development of the code of practice and obviously in relation to the whole timescale of the Bill. We have project leads in both the Department of Health and the Welsh Assembly Government who have been working on the draft Bill and indeed the previous draft Bill that came forward for pre-legislative scrutiny. There is no question that we are already mapping out how we would see a Welsh code of practice; I am partly giving evidence to you to encourage you to try and seek as much flexibility as possible in terms of the parameters and the principles of our code of practice here in Wales and indeed the secondary legislation, but we will have to deliver in time for commencement and we will have, as far as I am concerned, as much freedom as we hope we will gain as a result of as much of it being left to secondary legislation as possible, and the code of practice of course will be the guidance to implement that. That is something where, as far as you are concerned, you might want to have more on the face of the Bill; we want to have more opportunities for flexibility in secondary legislation and the code of practice.
Q542 Tim Loughton: Do you think we should be better informed by you giving us some indications of your likely code of practice before we get one in London? Should this be more of a two-way street with this Committee?
Ms Hutt: I hope I have given you some indication. You have had a lot of written evidence from other stakeholders as well as myself of our concerns about the draft Bill, but also you have had evidence about our strategy, our approach, our powers and responsibility in relation to our Adult Mental Health National Service Framework and strategies. I think you have also had evidence from me that we are interested in evidence coming forward about the use of exclusions in terms of impacts on the power of compulsion; I have already mentioned one area of concern about the approved mental health practitioner and we can go through the whole process of compulsion step by step and say these are our views, if that would be helpful - and I have given you two examples - but basically that the Welsh code of practice will have to be in line with the primary legislation is clear, it is how it reflects Welsh needs, circumstances and policies that we would want to see. I do not think there is more that you need to know at this stage except what I am hopefully giving you in terms of our policies and our Welsh circumstances.
Q543 Tim Loughton: It is not clear whether that differing code of practice is going to be based on the problems you have with the capacity you are able to offer and some suggestions that mental health services in Wales are a few years behind, or whether it is going to be based on some suggestions that you can do it rather better than the likely code of practice from London is going to suggest. Are you tailoring it because of the inadequacies of the service as it stands at the moment in Wales, or are you going to tailor it because you think you have a completely different approach that will be rather better?
Ms Hutt: No, this is about collaboration between the Welsh Assembly Government and the Department of Health. As I have said, we welcome the fact that there is new legislation, the Act has to be reformed, but we are concerned to ensure that Welsh circumstances and needs are reflected in the Bill, principally through secondary legislation, that is the evidence I am giving. In terms of the way forward, it is based and underpinned on not just the principles that have been laid out in the Bill but also on the principles of our mental health National Service Framework and strategy. We have to take into account our workforce, we have to take into account the readiness of our services, and that is key, but I think you will recognise that the evidence that is coming forward is also about the basic principles of this legislation in relation to compulsion and in relation to the equity and empowerment issues of service users. It is basically a combination of improving the legislation on an England and Wales basis - that is why I am giving evidence today - but specifically for Wales, and ensuring that we have as much flexibility as possible in our secondary legislation. The result of devolution is that we have that power within secondary legislation to shape things to meet our circumstances, but basically the primary legislative powers are what is going to be the key driver of this Bill.
Chairman: Mr Williams, do you want to raise any other issues briefly about the codes of practice before we move on to a question about the Care Programme Approach?
Q544 Hywel Williams: (Through the interpreter): Thank you very much, Lord Chairman. There are a number of questions arising in my own mind, but I would like to ask a very general question of you rather than go into too much detail here. Bearing in mind the complexities of having a different code of practice in Wales to that in operation in England, and the differences between implementing the service framework, did you give any consideration to giving pressure for having a separate Bill for Wales? If you did consider that, what was your opinion on that?
Ms Hutt: In terms of answering your first point, what we need to do in the code of practice is to involve Welsh stakeholders in the development of our code of practice, that is the way we work in Wales, involve them in it before it is finalised. It would be unusual to produce the code of practice at such an early stage in the process, I am sure you would recognise that as a Committee anyway, but in terms of this Bill there is clearly a function to Part 3 under the Home Office; we have to recognise that in terms of our opportunities it comes through secondary legislation and the code of practice.
Chairman: Thank you. Lord Rix.
Q545 Lord Rix: My question is not about the code of practice, but we were going to hear evidence later on from the Welsh Nursing and Midwifery Committee, and unfortunately they are not now going to give us that evidence. They refer to the Bill and suggest "that the removal of existing exclusions contained in the new Bill is an erosion of the public's protection, and may not be compatible with the Human Rights Act. Removal of these exclusions effectively broadens the grounds for compulsion." Would you agree with that statement?
Ms Hutt: I think I have raised already, Lord Rix, the concerns we have about the powers for compulsion and I have already in written evidence said that we are attracted to the exclusions that have been identified in the Scottish legislation, so we do have some sympathy with that and that is why I gave my response as I did.
Q546 Lord Rix: Can I go one step further? Obviously, I am referring to learning disability; as you know, learning disability is swept into this Bill by all the accompanying papers which we have had, but I am of the opinion that people with learning disability should not be in the Bill unless they have a mental illness as well, therefore they should come under these exclusions. I feel very strongly about this; would you agree with the exclusion of people with learning disability without the additional problems of mental illness?
Ms Hutt: Certainly, that view has been expressed to us very strongly by our Learning Disability Implementation Advisory Group, which has obviously drawn reference to the existing legislation which relates to people with mental impairment, that they only come under the remit of the current Act if associated with abnormally aggressive or seriously irresponsible conduct. The only other point I would make in this context is that within the new legislation we need to be also careful that people with learning disabilities do not then fall within the criminal justice system if they do not have protection, so that is my concern about the exclusion in relation to the Scottish Act. From the criminal justice aspect of this new Bill we have to protect people with learning disabilities from that eventuality and we need to ensure that we get the right treatment and support for people with learning disabilities.
Chairman: Lady McIntosh.
Q547 Baroness McIntosh of Hudnall: Minister, we have begun to touch on the issue that I wanted to raise with you already, but we have had submitted to us some evidence, certainly opinion, to the effect that mental health services in Wales are being provided on some rather outmoded models. Indeed, we have been told that practice in Wales and policy is less evolved than it is elsewhere in the UK; therefore the implication is that extra safeguards - if this is true - would need to be in place to ensure that the code of practice was developed to make sure that a Care Programme Approach was fully implemented and resourced. Can I ask you first of all whether you agree that mental health services in Wales are behind, both in terms of their modelling and their delivery and resourcing? If you do agree can you tell us why the Care Programme Approach is not fully implemented yet and whether or not the implementation of the National Service Framework in Wales will eliminate some of those differences that we now see between Wales and England?
Ms Hutt: Thank you very much, Lady McIntosh. In fact, part of this is historical and perhaps I can focus particularly on the Care Programme Approach since it is a key action in our National Service Framework. If we go back, the Care Programme Approach was introduced in England in 1991 and then through Building Bridges in 1995 guidance came through with strengthening guidance in 1999; in Wales, just to give you the historical picture, in 1998 the guidance first was initiated in terms of the Care Planning Process and then in 2002, through our National Service Framework, this Care Programme Approach became a key action and, in fact, this month (December 2004) we are expecting all our local health boards to deliver with their partners on the Care Programme Approach in Wales. So historically we were behind, pre-devolution, we had extensive consultation around our Adult Mental Health Strategy which led to our National Service Framework, which we feel is a robust National Service Framework, we have just had a review of it and the Audit Commission has done a baseline review for us. We also have appointed a new Director of Mental Health Services in Wales, again the first ever appointment of such a professional in the Assembly, so we are making progress in order to deliver, and through performance management we have a service and financial framework and we also have our National Service Framework key actions, so the Care Programme Approach should be delivered in 2005 across the whole of Wales, it should be in place. Performance management of course will be key and that will be done through our three regional offices of the Health and Social Care Department in Wales. As far as implementing our National Service Framework is concerned, there is huge enthusiasm backing it, it is a priority of the Welsh Assembly Government, it is a priority of the National Assembly for Wales and mental health is quite at the forefront of the political and public agenda in terms of improving services. We are investing more as an Assembly Government into Adult Mental Health Services and, clearly, our stakeholders are engaged in the implementation of it - they co-chair our Implementation Advisory Group - but our concern I think is that we deliver on our National Service Framework and that in terms of priorities and investment that is our focus - in terms of workforce development, workforce redesign, improving services that has to be our focus, and I am confident as Minister that we are on line to deliver our National Service Framework.
Chairman: Can I just link this with a question that I know Ms Moffatt wants to ask because I think the two tie together very well?
Laura Moffatt: They certainly do. Minister, I am very interested in what you are saying about the aims and objectives of getting to the point with the Bill or the Act, whatever it looks like, where the Welsh Assembly will be able to respond properly, and in your written evidence and in your evidence now you are talking about the changing roles of those professionals involved in that whole process. We know that there are acute shortages of staff, particularly in Wales - in fact, I believe the situation is more severe in Wales than it is in England and I wondered if you have given thought to how you are going to reach that establishment and what impact will that have on you reaching the goals that you have been talking about today if you have not got, particularly, psychiatrists in place and other professionals to be able to deliver the service?
Q548 Chairman: If you can give us some up to date figures on staff shortages in Wales it might be helpful - if they are readily available. I know you do not have notice of that question.
Ms Hutt: If I could perhaps start with that in terms of shortages, they have risen in terms of psychiatrists from 7.5 per cent vacancies over three months to 23.7 per cent vacancies over three months. We must also bear in mind that there has been a 21 per cent increase in posts established over the past three years and that has had an impact and increased shortages of psychiatrists, so this is a big issue for us. Clearly it is an issue in terms of how we deliver on the new Act, but just to give you a quick explanation of how we do our workforce planning, the Trusts do workforce planning with a five year forecast and also the Department of Health in collaboration with the Welsh Assembly Government has estimated how many additional staff are needed to deliver the new Act. In terms of workforce planning we have estimated that we need an extra 147 staff, and that is consultant grade psychiatrists, not just for the implementation of this Act but to implement our National Service Framework, our Child and Adolescent Mental Health Strategy, Old Age Psychiatry and Learning Disability, so that is our workforce plan, 147 extra consultant grade psychiatrists, and it is going to be a major pressure on us. I would perhaps just say also that we recognise this is not just about the psychiatrists, this is about other staff across the board. We have a retirement bulge in terms of mental health nurses, which I think is reflected in the rest of the UK, and we need to ensure that we take the opportunities that there are in this Bill for modernising the workforce and redesigning the workforce, which goes back to the point that David made earlier on. There are opportunities for workforce reform which the Bill gives us and for more multi-agency working, but it is a key standard of our National Service Framework that we do modernise our mental health workforce and attract and recruit those psychiatrists and the rest of the staffing complement that we need, including of course advocates and the other professions.
Q549 Baroness McIntosh of Hudnall: I do not want to labour this point because I can see that it is difficult and I do not doubt the goodwill and intentions that are expressed in what you have said, Minister, and in what you have submitted in your written evidence, but do you feel that there is a danger, given that we are being told that you are already in Wales somewhat behind in the delivery of these new mental health strategies, that the implementation of the Bill will put such pressure on your services that there is a danger that you will fall as it were further behind? I am sorry to put it in that rather uncomplimentary way but I am just trying to feel for whether there is a real danger of an active disadvantage growing out of the relationship between this Bill and your own strategies.
Ms Hutt: Certainly that is the major concern that has been expressed by our stakeholders, that it is the impact on delivering or National Service Framework and also the ability of the workforce in terms of delivery, because in terms of the use of compulsion we understand that if there is a 10 per cent increase in the use of compulsion, it could lead to a 20 per cent increase on their statutory duties in terms of the workforce. Clearly if we have the National Service Framework implemented - and can I just say that key actions relate to not just the Care Programme Approach but crisis resolution and home treatment as well as all of the issues relating to prevention and mental health promotion and tackling stigma - if all those are in place then I think it would be a better balance in terms of the implications of the Mental Health Bill in terms of implementation. That is the dilemma for me as Minister in terms of how I respond to you, in good faith, in terms of yes we need to modernise, yes we need reform in terms of the Mental Health Act we have now, but we in Wales have got to deliver on improving mental health services and have that in place. I think that is where we go back to have we the opportunity in our code of practice and secondary legislation to help achieve a balance in terms of delivery.
Chairman: Mrs Browning.
Q550 Mrs Browning: Thank you. You mentioned the shortage of consultant psychiatrists and other mental health staff and you have also talked about the need to establish a National Service Framework and then the implementation of this Bill post 2007. I just wonder how you are seeing this in terms of actually filling these vacancies, which seem absolutely essential. I know there is a national shortage, particularly of psychiatrists, but is it the case that it is that lack of policy and strategy being in place that puts people off applying for posts in Wales and therefore you need to really step up the timescale in which you implement something that is attractive, or are you looking at other ways of actually recruiting the people who you will need on board to help you develop that strategy and to implement it. If I could just add a supplementary to that, within that framework and that strategy and the need to recruit, how focused are you on the need, particularly in psychiatry, for specialisms within the field of mental health? I am particularly focused on the lack throughout the country and the very patchy and sporadic expertise we have in psychiatrists who also have an expertise in autism. I just wonder how you are focusing on those specialisms because it seems to me you have a pretty big mountain to climb there.
Ms Hutt: We do not see it as a mountain, we see it as a challenge and as a priority, that is the key for me as Minister. I have outlined already, and I will not go over it again, how we are putting into place our National Service Framework key actions, the service and financial framework, and health boards have to deliver not just on Care Programme Approach but crisis resolution and home treatment, so in terms of moving forward I believe we are going as fast as we can. Recruitment and retention is key; we have expanded for example our SPRs (specialist registrars) in psychiatry in order to grow our workforce in Wales, but also in terms of recruitment and retention we have just invested more into, for example, our Child and Adolescent Mental Health Strategy, and that in itself is having an impact on recruitment and retention because we are making progress in that respect. Turning to the needs in terms of sub-specialisms, interestingly, in Wales we are ahead of the UK in developing an Autism Strategy, which you might be aware of, and that Autism Strategy is going to guide the way in very similar terms to a National Service Framework about autism services across Wales. However, that does not just relate to health, of course, it relates to social care, education and all the other aspects of the lives of people with the autistic spectrum disorder syndrome. So we are up for it all in terms of timescales, recruitment and retention, investment, priority and recognising sub-specialisms like autism.
Chairman: Mr Prosser.
Q551 Mr Prosser: You have told us you are confident of meeting your National Service Framework requirements but, at the same time, you have listed some of the challenges, some quite large challenges that you have to meet. Are you confident that you can meet all of those challenges and come up to standards within the Barnett formula? Secondly, and specifically, with regard to the shortage of psychiatrists and other staff, to what extent is the requirement and the quite understandable requirement that new recruits should have linguistic skills in Welsh a barrier to your recruitment programme?
Ms Hutt: Both points touch on a couple of issues relating to resources; for example, our budgetary estimates for not just implementing our Adult Mental Health National Service Framework but also the implications of this new Act which, although we anticipate in 2006/7 will cost £3.8 million in addition, and certainly we are seeking as large a consequential as we can in terms of the Barnett formula from the Treasury and the Department of Health, there is an issue about how we deliver twin track - preparing for the new legislation and delivering the National Service Framework. That is our responsibility, it is hugely challenging and I realise that has had an impact in terms of the Bill - you want to scrutinise the Bill and see how we can improve the Bill, and I have talked about principles and practicalities in terms of my evidence. In terms of the equality of the Welsh and English language, which is our statutory commitment and framework, I am sure you will hear from the Welsh Language board that we have a Welsh language healthcare unit within the Assembly where we are promoting the opportunities, and indeed bilingual Wales, the Iaeth Bawb, is all about how we promote the opportunities. It is a very important aspect, but it is not necessarily the key issue for recruitment and retention because it is not necessary to speak Welsh in order to work in Wales, but obviously linguistically and in terms of quality services we want to encourage as many Welsh speakers as possible, not just psychiatrists but through all of the professions. Indeed, that is what we are driving to in our Welsh language policy. I would say that recruitment and retention has to be about investment, and I have talked about that already, I will not go over it, and we need to ensure that every aspect of our services are provided bilingually where appropriate.
Chairman: Dr Naysmith.
Q552 Dr Naysmith: I listened very carefully to what you had to say to Lady McIntosh in describing the various milestones that were reached, in most cases, a few years after they had been reached elsewhere. You say that mental health services and your National Service Framework are now very much a priority for you and for the Assembly, but what you did not do was explain why things were happening a little bit later in Wales than they were elsewhere. Do you have any explanation for that?
Ms Hutt: Dr Naysmith, I think I did give some explanation of the historical situation in terms of pre-devolution.
Q553 Dr Naysmith: You did, yes.
Ms Hutt: For example, the Care Programme Approach did not emerge in terms of the planning process as early as in England; also, in terms of the consultation we had for the Adult Mental Health Strategy, that was when the Assembly came into being and we did have widespread and extensive consultation to get what we felt was the best strategy for Wales and the best National Service Framework for Wales. Indeed, our involvement of users and carers in our planning and indeed in the implementation of our National Service Framework, the appointment of our new Director of Mental Health Services, has all positioned us very well to provide good mental health services in Wales and we want to get it right for Wales.
Q554 Dr Naysmith: Would it be fair to say that because you are taking a little bit longer over the process you expect to produce a better result at the end?
Ms Hutt: We would hope we were getting the right result for Wales. It is very challenging, it is a priority, along with cancer and cardiac - and there are obviously huge challenges in Wales in terms of health, we have high levels of poor health in Wales which has had an impact - and also we have started from a very low base in terms of, for example, our older estate, our Victorian hospitals. We are now replacing all of those and we are moving forward, but it is at a pace where we feel that what has emerged from this in terms of our policies and our involvement through the devolution process will result in robust and good mental health services.
Chairman: Mr Hinchliffe.
Q555 Mr Hinchliffe: I wanted to pick up on the comment on staff shortages. You gave an estimate, for example, of the number of psychiatrists that you need and of the vacancy levels. Are your figures based on an assumption of the service remaining hospital focused, and have you got projections in relation to staff shortages if you moved away from the focus on hospitals, because I think the differences that we see with Wales you could also spot in parts of England, there is different progress being made in various parts of England with the different stages that people are at. I am just wondering why you need so many psychiatrists if you are moving away from the current hospital focus of your service?
Ms Hutt: That is key, David, to the modernisation of the mental health services in Wales, key to the modernisation of our mental health workforce. In terms of the workforce planning, although we have not completed our redesign in terms of, for example, the closure of some of our larger hospitals to community provision, that is planned over the next five years and our estimates for our workforce plans do include not just adult mental health services but it does include - I have the figure of 147 more psychiatrists for example - CAMS and learning disabilities and old age psychiatry, as well as the implications of the Capacity Act as well as the new Mental Health Act. I can assure you that that is what we are moving to, it is the crisis resolution, home treatment, Care Programme Approach, multi-disciplinary team working. One of the things about the code of practice is that we have to build good practice across England and Wales, across the UK; codes of practice are an opportunity to acknowledge and enable good practice to be shared and that is why the collaboration across the UK - not just in England and Wales but in Scotland and Northern Ireland as well - is key to modernising our mental health services and I believe that is what we will be doing in terms of developing our code of practice.
Chairman: Mr Williams has an extremely brief final question.
Q556 Hywel Williams: (Through the interpreter): Thank you very much. This is a yes or no response to this one really: do you predict that in the code of practice there will be a right for people to be assessed through the medium of Welsh?
Ms Hutt: Certainly.
Q557 Chairman: Actually, that was a trick question because I have a final question to ask you really. Can you give us any examples of where you have actively chosen to differ from English strategy?
Ms Hutt: In terms of mental health or other aspects? We certainly have not gone down the route of foundation hospitals and of course we are moving to have free prescriptions shortly. We have variances according to Welsh needs and circumstances, and policies.
Q558 Chairman: Thank you very much. Thank you, Minister, very much, for bearing with our questions, dealing with them so efficiently and for working at the high speed which is always imposed on this Committee because there is so much material we have to face. We are very grateful to you for taking the time to prepare clearly so carefully and to speak to us today. Thank you.
Ms Hutt: Thank you.
Memorandum submitted by Health and Social Services Committee,
National Assembly for Wales
Examination of Witnesses
Witnesses: Mr David Melding, Assembly Member, Chairman, Health and Social Services Committee, National Assembly for Wales, Ms Kirsty Williams, Assembly Member, Health Spokesperson (Liberal Democrats), National Assembly for Wales, Mr Rhodri Glyn Thomas, Assembly Member, Health Spokesperson (Plaid Cymru) National Assembly for Wales, examined.
Q559 Chairman: Can I welcome our next group of witnesses? Can I just say this to our next group of witnesses - and this applies to anyone else who is going to give evidence partly in English and partly in Welsh, I have been asked to say that it would be helpful for the interpreters if you did one language per answer as it were; I know you know the way the system works here much better than we do. Could I ask you to introduce yourselves, starting first with Ms Williams?
Ms Williams: Good morning, my name is Kirsty Williams, I am the Assembly Member for Brecon and Radnorshire; I am a member of the Health and Social Services Committee, I speak on behalf of the Liberal Democrats and, in the first term of the National Assembly, when we looked at the first draft Bill, I was chairman of the Health Committee at that time.
Mr Melding: Good morning, I am David Melding, I am a member of the Conservative group in the Assembly but I am not the health spokesman, though I am the chairman of the Health and Social Services Committee here.
Q560 Chairman: Thank you for your written submissions and correspondence.
Mr Thomas: (Through the interpreter): Rhodri Glyn Thomas, I am the Plaid Cymru spokesperson on health and social services and while my colleague, Leanne Wood is on maternity leave, I am also the Plaid Cymru spokesperson on social justice.
Chairman: Thank you. Meg Munn.
Q561 Ms Munn: Good morning. You will have heard the evidence given by Jane Hutt about what she sees as the advantage of not having the principles set out on the face of the Bill, in that it gives the opportunity for greater flexibility within Wales in developing your own code of practice, but in the written evidence that you have submitted to us your Committee took a clear view that the principles underlying the Bill should be set out clearly within the Bill, and in fact you go so far as to say the current draft was not compatible with Assembly policy. Can I have your comments on this issue about flexibility and the benefits as opposed to the negatives of having the principles on the face of the Bill?
Mr Melding: First of all, can I confess a certain naivety about primary legislation because we are a secondary legislative body - insofar as that is a coherent concept - so it is perhaps not so easy for us to pass fine judgments on to what extent a piece of legislation can omit the basic principles and leave them to some other mechanism like a code of practice. It seemed to us rather strange that you did not have the principles informing a very comprehensive piece of legislation - certainly by the number of clauses it has - without those principles being explicit, and that was the view of some quite senior witnesses who spoke to us. There is an element of contradiction in our approach because in urging principles to be written into the Bill the principles may be rather antipathetic to what we would want and as we would see practice developing in Wales; so there was an approach from some people who gave evidence that if this was going to be a bad Act we would want as much scope as possible to improve it in Wales via secondary means, insofar as that is possible.
Mr Thomas: (Through the interpreter): Just to add a few points, Chair, I think that even if the principles of the legislation are clearly written on the front of the legislation, they should be actually implicit in the legislation and I do not accept therefore that a code of practice in itself would be sufficient to enable Wales to develop the kind of service for people who suffer mental health problems that is actually required. We as a Party have actually fought for separate legislation for Wales because of the specific needs in Wales and because of the nature of the service in Wales. We have heard of the problems with the National Service Framework in Wales and also, of course, there is the rural element in Wales where it would be very difficult to offer treatment in the community, which is actually in the legislation. Also, there is the special case of the Welsh language and, despite the fact that the Minister can say quite definitely that we can certainly offer a service in Welsh, I am not aware that it is possible to do that in many places in Wales, and in order to offer that service fully in Wales I think we would need to have much more variation from the legislation in England than we could ensure through the code of practice.
Q562 Ms Munn: To go on to talk about one of the key issues around the Bill, which is around compulsion, you have expressed concerns about the levels of compulsion that might be involved but also, particularly, you have mentioned those with substance misuse problems and people with personality disorders for whom there is no clear course of treatment. One of the most interesting areas that we have had big discussions about is around people with personality disorders and whether, in fact, in the past there has been tendency by some psychiatrists to use that label as an excuse not to provide services - indeed, we have had some level of admission that that has been the case. What I would like to know really is whether that is an issue that you have discussed and come to a view about in terms of actually providing services for people who previously, perhaps, have not received those services, and whether that is then needed to be done compulsorily or not.
Mr Melding: I think the view the Committee took - and certainly it was strongly emphasised to us in evidence - is that the reason for giving compulsory treatment in mental health law is that they have a mental health condition. There may be other factors associated with behaviour, and in the explanatory notes some very vague concepts are used like sexual deviation, promiscuity, addiction to substances for instance. In a dual diagnosis sense you may have that present, but it seemed to us strange to have such a wide definition of what would be a mental disorder; it would need a mental disorder as well, some people would argue, for some of those conditions, and I think that was the view of nearly everyone on the Committee. I do not know if you want to add anything, Kirsty.
Ms Williams: The Committee's main concern is on issues around compulsion that we have focused on and it came from the evidence that we received, that if somebody were ill enough to be subject to compulsion then they should be in hospital - that is with regard to compulsion in the community - but also there were concerns that, given that the definitions were so broad, it would lead to a broadening of the categories of people who might fall into this trap. The issue of compulsion also might lead to people being trapped in a long term predicament of being in compulsion whereas it was seen desirable by the evidence that we received that compulsion should be only a short term measure, and that under this system potentially people could be trapped for almost a lifetime in a cycle of compulsion. With regard to specific personality disorders, the Committee did not actually hear any specific evidence on that but there was a general feeling, both in 2002 when we took evidence and indeed this time, that the Bill perhaps concentrated too much on a potentially small number of people who might fall into that category rather than the broader number of patients who would need treatment, and the issues around compulsion then would potentially stop people from seeking treatment at an early stage and also divert resources away from the majority of people needing mental health services to be focused very much on the few.
Chairman: What you have just said has produced mind waves from Lord Rix who I feel sure has a question to follow that up.
Q563 Lord Rix: Indeed. You recommend specific exclusions from the Bill rather than a tightening of conditions for the use of compulsion; would those exclusions from the evidence you have taken include people with a learning disability without additional mental health problems?
Mr Melding: I do not think it was actually put to us directly but I am sure I can infer justifiably from the evidence that we received that we would exclude people with learning disabilities unless there was an accompanying mental disorder.
Q564 Lord Rix: Thank you very much.
Mr Thomas: (Through the interpreter): I noted that Lord Rix asked this question to the Minister also and I would agree with him entirely that the definition of mental disorder within this particular draft Bill would mean that there would be people who do not have any mental health problems but do have special needs in terms of personality problems who will be drawn into this also, and this element of compulsion will be placed upon them. The Law Society in Wales has suggested that the broadness of that definition of mental disorder would mean that people's fundamental rights would be undermined, and that there is a danger that the Bill would actually contradict the European Human Rights Act.
Q565 Mrs Browning: Similarly to Lord Rix, people with autistic spectrum disorders would come into the same category, although we all acknowledge that they can of course have a mental disorder on top of that. A lot of our deliberations have touched on the Bournewood judgment which specifically involved an individual with an autistic spectrum disorder, and we await the Government's recommendation on that, but could I just ask you - and I asked the Minister this - you are going to produce a national framework for autism in Wales, which I think is absolutely wonderful, but have you thought about the resources, not just for psychiatrists and in-patients, which is what I asked the Minister, but also resources in the community, because a lot of support in autism and keeping autistic people out of mental health services is actually providing the right package of support, and it involves things like housing and social services support. Have you looked at what you think should be done in terms of resources there?
Mr Melding: May I start, Lord Carlile, by declaring an interest, I am trustee of Autism Cymru, I think that needs to be made clear. We very much welcome the decision of the executive here to form an autism strategy - I understand it will be the first anywhere - but I think it is fair to say that we have been slightly disappointed that it has taken a little while, it has been about two years in gestation, I think, but that may be a meagre comment because it is innovative and there is not any practice to emulate. The Committee will, I think, want to look at the actual strategy when it is produced and I think if in an analogous way I can compare it to the Adult and the Child and Adolescent Mental Health Strategies, one of the main criticisms we had was that there were no dedicated resources attached to it in addition to current practice, it was more or less passed on to the commissioning bodies as something to inform their future commissioning, whereas I think in England there was more readiness to top slice monies. We felt if you are really going to prioritise something you need, certainly in the short to medium term, something as vigorous as that, otherwise you may not shift commissioners very much from their current practice. I would say my experience of autism services, certainly in South Wales, is that they are very under-developed. Insofar as they exist it is because you have a psychiatrist who also happens to be interested in autism, rather than someone who is appointed as an expert in autism and, whilst they often become experts, that is not necessarily why they were appointed initially. That is a weakness, I think, but you could say that of quite a lot of services and the Government of course quite fairly could say that that is one of the reasons they have a strategy because they now need to improve.
Q566 Chairman: Forgive me for interrupting, but can I just pick up a point? As somebody who represents a rural area, Ms Williams, would you say that the problems Mr Melding has highlighted from Cardiff, which is an urban area, are sometimes squared in the remoter rural areas of Wales where there is a great shortage of specialists in almost anything, let alone the autism spectrum?
Ms Williams: Absolutely, and I think that would be in true in terms of autism services, and it is certainly a huge concern for mental health organisations delivering services and representing patients in rural areas with regards to this Bill as well. There simply is a real fear that the problems experienced in urban areas will be squared in rural areas because there is even more difficulty in recruitment and retention of staff often in rural areas, because the opportunities for wider practice and promotion and progression in your career are more limited in a rural area, so it is much more difficult in rural areas, often, to have access to services of a type that may be available in some of the urban and more highly populated areas.
Mr Thomas: (Through the interpreter): Just to add to that - and I agree with what David and Kirsty have said - I would give one warning regarding the autism strategy: that is at present being discussed internally and is not going out to be consulted upon until next Spring, so we are not really clear at present what the content of the strategy will be. In principle it is a good thing and there are many good suggestions being made, but will they actually be included in the paper which will go out to consultation? We will have to wait and see. I would also say that part of my constituency is a rural area, and I have an additional problem in Carmarthenshire which is the provision for Welsh speakers. If there is a general problem in terms of offering a full provision for people who suffer from autism, that problem is huge for Welsh speakers. I have had a great problem in ensuring fundamental rights for school pupils who suffer autism, to get the full provision through the medium of Welsh, despite the fact that there is a bilingual education policy in the area. I know there is a problem with numbers, but I think there is a responsibility to provide fully through the medium of Welsh as well as through English, in a county which is a bilingual county such as Carmarthenshire and in Wales which is supposed to be bilingual.
Chairman: If the strategy has the gestation of an elephant at least it will be as obvious as an elephant when it appears. Mrs Blackman?
Mrs Blackman: Can I just make an observation; I am chair of the All Party Group on Autism in Westminster and we had an excellent presentation of the very holistic approach that is taken by Rhondda Cynon Taf. Yesterday I attended a Welsh Children's All Party Group where there were representatives from Powys who were presenting their work on autism; they are next door to each other but what they had not done was joined up and shared best practice. That is the same in England as it is in Wales, there is some good practice out there but it does actually need a bit more joining up. Let us hope this strategy does that.
Q567 Chairman: Is anybody going to disagree with that trenchant and completely coherent view?
Mr Melding: No.
Chairman: Mr Hinchliffe.
Q568 Mr Hinchliffe: You heard me ask the Minister a question about your position on approved social workers and probably I should declare, as you may already be aware, that I used to be an approved social worker, and it is quite a pleasure to read politicians saying nice things about social workers, it does not happen very often in my experience. What I wanted to press you on in relation to the evidence that you have put forward is do you have reasons, experiences and specific evidence to lead you to believe that professionals other than approved social workers - and we are talking here primarily of health professionals - might be more willing to section people than approved social workers? Are you suggesting that they could be led by a psychiatrist or a GP more easily, perhaps, than an approved social worker? If you are, what is your evidence?
Mr Melding: I do not think we received evidence on that specific point, although we received evidence from all who did comment on the role of the approved social worker that that should be retained, and that it was a robust element in the sense of the team that was dealing with very difficult issues on compulsion on someone from social care and with obvious interests in the person's reintegration into society and the community. We were not convinced, despite explanatory notes saying that there would nearly always be a social worker, that there was a reason to move away from that model. I am not quite sure how predictive legislation is meant to be, but to talk about what might happen in 20 years seems somewhat speculative and I do not think you can hold up legislation just on one issue like that and say we had better put it in just in case; presumably you could amend it at some future point. I think the precautionary approach is appropriate; if I was in your position of dealing with primary legislation - because of course we are not - I would want to see evidence. It was not obvious to us and certainly witnesses such as the ADSS were very concerned about this although, in fairness to this draft, they did note that at least the power of appointment was back with the social services authority, so that was welcome.
Q569 Mr Hinchliffe: Was there any kind of philosophical background to your Committee's position on this in terms of a fear that the Bill could be over-medicalised by moving away from the approved social worker?
Mr Melding: The general view that we had - before I ask colleagues to comment - is that there would be more compulsion with this legislation; whether that is the actual intent or not, that would be the practice. It may be a fear that would not be borne out by experience, but it was strongly held by everyone who gave evidence to us.
Ms Williams: Certainly when we heard from the service users and carers there was that concern, that this Bill did have a very strong focus on medical aspects of mental illness rather than a more holistic approach, and the service users and carers all felt very strongly that the approved social worker did allow for a certain independence that might not be there if that was also taken up by a medical professional, somebody who was employed within the NHS structure who did have working relationships with other people within their local NHS. It was seen as an element of independence to have somebody from outside the NHS providing that role, who perhaps was looking at that service user in a more holistic way, rather than just focusing in on the medical needs and the treatment needs of that person. That was a strongly held view by all service users and care representatives that we heard from, although I must say that we did not have any specific evidence that would suggest that people would be more likely to be sectioned, but there was a very strongly held perception and view.
Q570 Ms Munn: I am a little concerned about this view because David Hinchliffe said earlier that there is a general moving together of health and social services, and certainly in the city I represent we have a Mental Health Trust and the social workers and the community psychiatric nurses actually do work for the same organisation, so this issue of independence which you are identifying here does not exist in fact in many of the services in England now. But I would also take the view that what we are striving for is for all mental health professionals to be dealing with people with mental health difficulties holistically, and if you actually look at the roles that a community psychiatric nurse takes as opposed to a social worker, my contention would be that those have come much, much closer together with the nursing aspects of the community psychiatric nurse perhaps being a minor element as opposed to the general support element of their role, and that that overlaps considerably with what a lot of social workers do. While there may be some benefits therefore in having people with different professional training which leads to that, I really cannot see why there would be too much of a concern about having all professionals acting on some issues the same and taking a holistic view. Surely the way you deal with that is by having good practice guidelines and inspection of standards and the way people are operating, rather than relying upon structures which are, frankly, becoming outmoded to deliver those.
Mr Melding: I accept that you can have a more constructive interpretation of what is proposed and of those circumstances, although I do note that in the explanatory notes the assumption still seems to be that this person will be the mental health social worker. The point about authorities working more closely together is clearly an important one, and the policy in Wales is the same as in other parts of Britain, that that has to happen, and I do not think anyone thinks, in the team that is responsible for the care of an individual, that we would see such dramatic divisions or the nurse not playing a more expansive role, if that is appropriate. So I do not see any block on the way these teams evolve, and if joint working mechanisms become even more closely integrated in terms of budget-holding and all the rest of it, then we would welcome that, but I think the general view of the Committee was that if the approved mental health professional is a social worker, that sends a very clear message to society in general and we did not want to move away from it. We felt that if practice leads us there eventually, then perhaps you could review it then, but at the moment it would say something that we are not ready to say or that indeed we do not think should be said by many people, and there was a very generally held fear - I am not saying it was more than that - that it would be a retrograde step.
Ms Williams: (Through the interpreter): Thank you very much, Lord Chairman, I would agree entirely with the need to develop a team ethos and to have this holistic principle established very clearly, but although we have not received any direct evidence on this issue I do think it is fair to say that we have received some quite frightening evidence as regards the way, sometimes, the medical aspect actually deals with the problem of people who have mental health problems. I remember people telling us that they had gone to see the doctor and that the care plan had been prepared beforehand, before the doctor had even spoken to them; other evidence told us that the doctor was speaking to them through a third person - I think this lady had taken her sister with her and the doctor was talking to the sister and she was not included in the discussion, although she was the person who was suffering the problems. So I do think those examples have actually fixed in our minds the kind of problem that can arise, but I would hope that this holistic element would mean that standards would be generally raised and that the provision and the quality of provision would be improved across the board of health professionals dealing with those with mental health problems.
Ms Williams: It seems from what has already been said this morning that you have heard that practice in Wales is perhaps behind practice in England, and that is perhaps why Ms Munn's viewpoint is coloured by the fact that practice is better evolved in England and the experience of practice as it currently is in Wales makes our service users and our patients very, very fearful of this particular change. So maybe your confidence is in the fact that your services are more developed than ours are here, but our evidence is shaped by the experiences of people in Wales as they experience service delivery at the moment.
Chairman: That nicely brings us to a question Dr Naysmith was going to ask.
Q571 Dr Naysmith: It is interesting what has just been said, and really this question has been asked and answered already, but since it is such a trenchant question I will put it to you and see what reaction we get. The Welsh Nursing and Midwifery Committee has stated that the Welsh National Service Framework has hardly been implemented yet in Wales and they also told us in written evidence that mental health services in Wales are ten years behind those in England and that the service is still largely reliant on Victorian institutions as the 'hub' of care delivery. Do you agree with that and, if you do, how does this affect the ability to implement the Bill?
Mr Melding: I am not quite sure whether we are ten years behind or whatever, but I think we are in a position of seeing a major change in legislation at a time when we are trying to develop the basic care model for mental health. It is difficult to think how the legislation might affect that in a very constructive way, it would seem to be better to implement these important changes and then have a stable situation in terms of the care model and then review the legislation, but we are in a position where we legislate for England and Wales and that is where we are at the moment. In terms of acute care, the situation of the hospital stock is really very poor. My last visit a couple of months ago was to a hospital for adults, with 20 beds or so, and I just asked "Are there any children or adolescents currently being treated?" They were very embarrassed, the person looked at the chairman of the Trust, but they had to answer the question as it was such a direct one, and there were two adolescents at that time being treated in that adult hospital. That is not uncommon in Wales.
Q572 Chairman: Would you wish to ban it in Wales?
Mr Melding: I think it is completely unacceptable, and most people would say that, but it still happens, and if it happens then the fact that we promise that it will not happen in three or four years is pretty weak. Four or five years ago we closed down one of the main acute hospitals in this part of Wales, and that hospital had been designed as a TB hospital; it had particular problems with observation because of the way it was constructed - it was for the reverse of observation, to give lots of people air in a private way - in the 1930s. That was closed, quite rightly, in the end because the Royal College of Psychiatrists would not permit their members to practise from there, but we had not prepared new facilities so we then had the current hospital in Whitchurch, which is a Victorian one, being over-used and that has to be modernised as well. We still do not have the replacement units from the closure of the Sully Hospital (the one I am referring to) and I think that is part of the problem, our services really are not fit for purpose for modern mental health care.
Dr Naysmith: We will be visiting Whitchurch this afternoon so we will wait and see for ourselves.
Chairman: Given the good Gladstonian principle of self-flagellation, leaving aside the ten years point - which is perhaps pejorative - I think all those of us who function politically in Wales know that it is very easy to raise money for certain subjects in health care, like scanning machines and almost anything connected with children, as a reality of life - and it is perhaps unfashionable to say so but I think it needs to be said - but it is extremely difficult to raise money in the voluntary sector for unattractive health care provision like mental health, and elected politicians are naturally prone to the effect of public pressure. Do you think that is a reasonable statement and, if so, how are you going to redress it?
Dr Naysmith: That is not just true in Wales, that is true everywhere.
Q573 Chairman: Yes, but I function politically in Wales so I am merely putting the Welsh viewpoint. If that is, as Dr Naysmith says, true everywhere, how are you as the Welsh Assembly Government going to redress that balance so that whether you are one month or ten years behind, given your diversity and rurality in the Principality, you are able to do what everyone must require which is to meet need. Do you want to start, Mr Thomas?
Mr Thomas: (Through the interpreter): Thank you very much. May I say clearly in the first place that we are not the Government of Wales, we are actually the opposition parties, the Minister is the Government of Wales and we live in hope, Lord Chair. Perhaps the situation will improve when that happens, but I think you are quite correct to say that it is very difficult to get interest and financial response from the public to services and provision for people who suffer mental health problems, this stigma is still around and society in general wants to push the problems to the sidelines, hoping that we can ignore the situation. I think there is a responsibility on politicians of every party to try and educate people about the needs and to look at mental health problems in the same way as we look at physical health problems, and that we are willing to respond in the same way. In terms of where we are now, in terms of the National Service Framework at present, the fears I have, looking at this draft Bill before you, is that the dependency of the draft Bill on the National Service Framework means that because the service in Wales - and we can debate how many years behind we are - is significantly behind, and in terms of recruitment problems we have in Wales and the specific problems we have with regards rurality and rural communities and the landscape of Wales, the compulsion will put so much pressure on the National Service Framework that it will be impossible to catch up. The nature of this draft Bill will make the situation much worse in Wales and rather than actually catching up I am afraid we will actually be falling back because of the pressure put to bear on the National Service Framework which is already deficient. We have a double problem, therefore, Lord Chair, in trying to get people's support financially and in terms of empathy with mental health problems, and also the problems we have in terms of our National Service Framework.
Q574 Chairman: Do you want to add anything, Ms Williams?
Ms Williams: I take a very pessimistic view and I do not think that elected politicians will change unless we enjoy the benefits of non-elected politicians, and therefore you do not have to worry about the public and playing to them in that sense. One of the concerns is that we have got limited resources here in the National Assembly for Wales, the question of Barnett was raised earlier and there are lots of things that health spending can be spent on. The evidence that we received was very concerned that implementation of this Bill in Wales would take money away from implementing our National Service Framework, it would divert resources, our meagre resources, and although the Minister says and has said consistently since 1999 that mental health services were one of the top three priorities for herself, we are three or four years into our Child and Adolescent Mental Health Services and only now, in year four, have we seen the first ever dedicated resources going into that service. The real problem I think with this Bill is that it will take money away from what we are trying to implement in Wales.
Mr Melding: Can I just say something on the issue of stigma and information? I do not think the public are obdurate and bloody-minded about mental health, it is that there has been a lack of leadership and perception. Also, people are vulnerable to mental health illnesses; 25 per cent of the population will have a diagnosable illness that should be treated. I am the only politician I know of in this Assembly who has acknowledged that I have suffered depression and anxiety in the past, and it is difficult I think to speak candidly about these things. Until politicians can provide role models or give some leadership about how we should talk about mental health issues, I think we always will have a danger when it comes to looking at compulsion and the threat that some very ill people might pose if they do not receive treatment, but we do need to get across the more positive message about how effective therapeutic and drug treatments can be and how much hope there is for people who have suffered ill health. This is ill health, people do not ask for it, it is a vicissitude of life, it occurs, people get it. I hope I am not pre-empting you, chair, but at some point I would have something to say about the codes of conduct and how the Committee might deal with secondary legislation in terms of the timetable. I just say that now in case we run out of time very soon.
Chairman: Lady McIntosh, and then we will return to that point - unless that is the point that Lady McIntosh is going to return to.
Baroness McIntosh of Hudnall: It is not, Chairman, I will be as brief as I can. I just wanted to say that I do agree very much with what Mr Melding has just said about the necessity for there to be a greater degree of openness about these issues, but related to that I wanted to ask our three witnesses at the moment, who all have constituencies, whether there are any particular kinds of mental ill health that relate to, for instance, rural communities that are different from those that have, on the whole, tended to be the higher profile kinds of illness that the Bill directs itself towards, i.e. potentially dangerous kinds of disorder. For instance, is there a noticeably higher incidence of depressive illness in rural communities, and is there anything that the Bill can or should be doing to identify these regional differences, not just in provision but actually in the incidence of mental illness?
Q575 Chairman: Let us start with the farmer's wife.
Ms Williams: I have, since 1999, attended too many funerals of my constituents who have committed suicide, too many, and this problem has been exacerbated by the huge stresses and strains placed upon rural communities following the foot and mouth outbreak. There are a number of reasons for that: in rural areas you are perhaps more isolated, it is more difficult simply to get yourself to a service, if you feel well enough to even want to get there it is more difficult to actually get there, often in many of my communities we have access to the means of committing suicide in a way that some people do not - I am thinking of guns, people have access to guns in a way they probably would not have in another area - but I think there are also issues around isolation in rural areas that potentially can make people feel it is harder to get services and to ask for help. We are also a community where everybody knows everybody else and therefore the stigma that we have talked about perhaps in some ways is even greater in a rural area because people gossip and talk and, if you approach someone, it is only a matter of days it seems before the rest of the community knows about it. That might be a problem as well in rural areas, the stigma.
Q576 Chairman: It might be worth adding in relation to Lady McIntosh's question something about this: I think I am right in saying, am I not, that the farmers organisations - of which there are three in Wales - have taken initiatives to deal with rural isolation problems, including the setting up of helplines. Is that right?
Ms Williams: That is right.
Mr Thomas: (Through the interpreter): Yes, certainly, there has been an attempt by the agricultural unions and other organisations in rural areas to try and ensure that helplines are available for people, particularly those working in agriculture, because of the financial strains on the agricultural industry and this element of loneliness and isolation that Kirsty has referred to. I do think that the point she made about the nature of our rural communities and this inherent pride which exists within rural communities, they do not wish to talk about their problems. David has talked about the need for politicians to be more open; it is certainly a very great problem in close-knit rural communities. I had a very unfortunate case in my own constituency where all those elements had actually led to a murder; people were not willing to accept that a neighbour had a mental health problem, but if that could have been seen earlier then the whole situation could have been avoided. In terms of the difference in Wales, of course the Welsh language is used in many of our rural areas - I represent a constituency in Carmarthenshire where the largest number of Welsh speakers actually live and there are similar problems in Mr Hywel Williams's constituency in Gwynedd and also in Ceredigion. I am a little fearful that given the pressure on the service in Wales to respond to this legislation, it will be extremely difficult to offer that provision through the medium of Welsh, particularly with this element of compulsion. If someone is under a compulsory order then they are in a very, very fragile situation and they are not going to insist on a service through the medium of Welsh, even if that is the most appropriate service for their needs; even if a person is actually able to speak Welsh and English it does not actually follow that the provision through the medium of their second language will be appropriate for them, given their condition and they are not going to insist on provision through the medium of Welsh. If that provision is not in place for everyone then it is not going to be used and perhaps some people who are in very fragile situations will suffer. I would ask you kindly to consider those needs experienced by first language Welsh speakers, their needs and also the rights that they have to have a full provision in their own language.
Q577 Chairman: Mr Melding, let us return to codes of practice and what you wanted to say to us, if you could say it as concisely as possible.
Mr Melding: The Minister said the code would have to be delivered in time for commencement. There have been instances and, in fairness to the Minister, I do not doubt her goodwill for a moment, but certainly in terms of the new GMS contract, for instance, and also now the pharmacy contract where we are having similar difficulties - although there I think it is because the negotiations have been led on an England and Wales basis - the executive is in a position where they cannot table for the Committee's consideration in time the draft codes or the draft legislation or whatever and we end up not being able to consider it or only considering it in a very brief meeting. Secondary legislation is just one of the areas that we work on and we may spend an hour every three weeks, we only meet as a committee once every three weeks, there are about 12 meetings a year, so it is very pressured. I know the Committee would be concerned that it had enough time to give careful deliberation, especially if the Minister is successful in getting terms that will allow as much flexibility as possible. I would have to say, with past practice, I could not guarantee that we would have as a Committee the time necessary that we would want, it could be quite rushed and we would be faced with this law now being repealed before it has to be commenced.
Chairman: Far be it from us to comment on your procedures. I think we may
have views but we will restrain ourselves. Can I thank you all very much for
giving such cogent evidence to us and taking so much trouble, and for the
correspondence we have received too.
Q578 Chairman: Ms Cowie and I possibly could have had some of this conversation on the lane on which we both live; however, it is very nice to see you both in Cardiff at this meeting of our joint Committee. Would you like to introduce yourselves, first, and I would remind you before you do that the meeting is recorded. There will be a transcript available in about a week; you are able to corrections of text but not of substance and please would you be careful to speak up so that we can all hear you. Ms Richards first.
Ms Richards: My name is Mag Richards, I am a mental health development worker, I work in Powys. We work in the voluntary sector and I have been in post for a number of years, working across Powys.
Q579 Chairman: Could you, in introducing yourselves, just give a very short description of what Powys is and the nature of the provision?
Ms Richards: It is quite difficult to get your head around Powys because it actually covers a quarter of Wales. It is affectionately known as the "empty quarter" because that is basically what it is. It is about 120 miles north to south, 20 per cent of its population speak Welsh but it has a very small percentage of people from ethnic minority groups currently living in it. It is distinct for its extreme rurality, it has a very low population density and it has one town with a population of over 10,000, that is the largest town in Powys.
Q580 Chairman: Which is?
Ms Richards: Newtown.
Q581 Chairman: Sorry, it was not a test question, I just thought they might like to know. It is about 11,000 or is it 12,000 now?
Ms Richards: Just a little anecdote, apparently if you use public transport to travel from north Powys to south Powys it takes five days.
Q582 Chairman: Ms Cowie, did you come by public transport? Whether you did or not, please introduce yourself.
Ms Cowie: Celia Cowie, I work for Mag Richards, I am a development worker in Montgomeryshire, north Powys, working closely with users and carers and I am myself a carer.
Q583 Chairman: Does either of you wish to give an introduction, or can we continue with questions?
Ms Richards: I think it might be worth just saying really that our major concern about this Bill is that in rural areas such as Powys - and Powys is an extreme case of rurality - we have currently a very low baseline of services and we have some examples of the sorts of numbers of people we are talking about.
Q584 Chairman: The Committee would be interested in that.
Ms Richards: Just to give a couple of examples, our out-of-hours mental health service is run by one ASW to cover the whole of Powys.
Q585 How many consultant psychiatrists do you have working in Powys in terms of equivalents?
Ms Cowie: I have that detail because we had a report from the Centre for Mental Health Service delivery, Dr Les Judd, who did a report on the reconfiguration of services following the closure of Talgarth Hospital in March 2003. Powys has the lowest level of consultant posts in Wales, we currently have 2.8 whole time equivalents; our local health board has said we need 5.4 and that is before we have to deal with this new Mental Health Bill. That is for consultants, we also need staff grade posts and senior house officers. We have a huge number of vacancies and problems with recruiting staff: we have been unable to fill a post in the north - we need two consultant psychiatrists in the north - and we are on our 13th locum psychiatrist. Can you imagine the effect of that on users, who see a different locum psychiatrist every four weeks, each one changes their medication without regard to any good or bad effects from the medication, it is very demoralising and disheartening. We have one ASW on call, covering the whole of Powys, we need a further eight or nine approved social workers to come up to scratch, before we are even talking about the new Mental Health Bill. At the moment our acute unit is closed due to shortage of staff - our only acute unit in Powys.
Q586 Lord Rix: Could I ask a question which is actually not related to mental illness as such, but is about learning disability, in as much as the All Wales Strategy for Mental Handicap, which came in in the Eighties, did that kick start services in your part of the world for learning disability?
Ms Richards: I will answer that because actually I have got two sons with severe learning disabilities and live in Powys. The All Wales Strategy for people with a mental handicap has actually been a very, very successful innovation in Powys and it actually allowed us to close two large hospitals and to provide services into the community, but then there was a lot of money tied up with those hospitals and it was possible to provide the service at quite a high level. That is not the case in the mental illness field.
Q587 Lord Rix: So the hospitals were allowed to recycle the money into learning disability services were they?
Ms Richards: Yes.
Q588 Chairman: I think you are referring to Bryn Hyfryd and Llys Maldwyn.
Ms Richards: And Bron Llys, we had three.
Q589 Chairman: Is care in the community functioning well as a result of simply recycling that money?
Ms Richards: From my personal perspective as a parent, yes, excellent; my two sons get a very good service locally from that in the community.
Q590 Lord Rix: Could that not be replicated for mental health, or is it just a question of money?
Ms Richards: I think there is an issue about money, I will be perfectly honest about that. I will give you an example: when the consultation document came out about the closure of our large psychiatric hospital in Powys, one of the stated objectives at the time was to save £1 million, that is what the Trust were saying. That was a key objective of closing the hospital because it was a way of meeting their deficits. I think the sorts of monies that have been tied up in the learning disability services are not tied up - certainly they are not tied up in Powys - in the mental illness service, and my own view, as someone who has been involved in the mental health service for a long time, is that we have seen a gradual erosion and ripping away of resources through the closure of wards bit by bit over the years, and we have actually lost resources. This will not be a very popular statement but in Wales I do not think that we have had an adequate investment into mental health services - certainly in Powys we have not.
Chairman: Mrs Blackman and then Lady Eccles.
Q591 Mrs Blackman: I was actually going to ask about the funding. Are you saying that there has not been a significant increase in health funding in Wales, or are you saying that the decisions where to distribute it do not accord with your priority which is mental illness?
Ms Richards: What I think I am saying is that we have not seen money coming into the mental health service in Powys.
Ms Cowie: Especially in rural areas; we lose out because we get no money in the health inequalities because the towns and indices of poverty do not recognise that we have very deprived areas in Powys.
Q592 Mrs Blackman: That is very relevant to the inquiry, but given also that there is some money available but it is not managing to fill vacancies in the area of Powys, have you got any observations on how recruitment and retention strategies could be improved in order to fill the vacancies that would be funded if you could find the right carrot?
Ms Richards: It is very difficult for us because we work in the voluntary sector, but it is a big issue in Powys and Celia has got some figures on where the vacancies currently are. We have been looking at how can look at slightly different ways of providing a service in rural areas, looking at different posts and different ways of dealing with the service, and I think that to us that is the major concern about this piece of legislation, because in rural areas you have to do things differently, you have to look at more creative ways of doing things, you have to look at how you can use your local resources more effectively. What we feel very strongly about is that this piece of legislation seems to bring together two things from our point of view; it brings together a health imperative in order to look at the replacement of the provisions under the 1983 Mental Health Act, but it also seems to us - and this is perhaps not other people's perception - that it is driven by a public safety dialogue or agenda which is coming, we see, from the Home Office. So while we are looking at creative ways of doing things - which is about actually making the service more accessible to people across, as we say, the empty quarter - at the same time we have got this piece of legislation on the horizon that is talking about a completely different style of service delivery, from our perspective, because it will be about how do you enforce compulsion, how do you enforce Community Treatment Orders, how do you ensure that you have enough psychiatrists and nurses to undertake the legal requirements of this piece of legislation? So from our point of view there is a major conflict between what we would like to do and what the National Service Framework tells us we can do, and what this legislation is saying in the background.
Chairman: We will return to that point in a moment, but first Lady Eccles.
Q593 Baroness Eccles of Moulton: I was rather worried about diverting from what was clearly a very interesting and important train of thought, because I wanted to revert to something you said earlier about when the funding was released from the closure of the hospital and it was therefore available to provide a much more effective learning disability service in the community, but you were able to resource the community service with the required volume and skill of people. It could be a very effective steer to what could be done if funding was released for the same sort of switch in the mental health area, and I wondered whether you could just confirm that this had been possible.
Ms Richards: I think what I was saying earlier on is that we had three large learning disabilities hospitals in Powys, tying up a large amount of resources. They have now all closed. We also had a fairly large psychiatric hospital - only one - at which over the years the number of patients has diminished dramatically, but the savings from those individual ward closures have not been quite the same as when you actually close a large institution in one go, so what I was saying was that the psychiatric hospital was closing over a long period of time by shrinking. When it actually closed at the end of the time the potential savings were much more limited than they had been potentially much earlier on.
Q594 Chairman: Is it right, just to put this into its full context, to remind the Committee that there are in-patients from Powys but they are in hospitals outside Wales, for example in Shelton Hospital in Shrewsbury and elsewhere along the border?
Ms Richards: That is right.
Q595 Baroness Eccles of Moulton: The point that I was driving at, though perhaps not very clearly, was when the learning disability excellent service was provided in the community, it was possible to find people to come and work in that area.
Ms Richards: Yes, it was, but we are talking about much smaller numbers of people, because we are talking about one in a hundred, somebody who may have a learning disability, whereas what we are talking about in the mental health field is one in four of the population possibly having a mental health problem, so we are talking about completely different numbers of people.
Q596 Baroness Eccles of Moulton: The scale is not comparable.
Ms Richards: It is very different, yes.
Q597 Mr Hinchliffe: You have described a situation where you have one out-of-hours ASW for Powys, your acute unit is closed at the moment. Have these problems driven thinking about alternatives to the traditional approach where a person has a problem, because certainly I found in various parts of England in particular that they had moved away from a reliance upon admissions and compulsion, in some respects having been forced to, and it is not that long ago, when you look at the history of how we have developed our mental health services, within my working lifetime I was involved in removing women from long stay hospitals who had been there for years, before I was born, as a consequence of having a child out of wedlock, moral defectives. It seems that sometimes we are rooted in this institutional kind of framework, and I just wondered whether the problems that you have had have driven any radical thinking away from our traditional dependence - and there is probably more traditional dependence in Wales than England currently - on institutional provision.
Ms Richards: I think it has, I think we are really getting to grips with that right at this moment. We have just pulled together a three year strategy which is actually looking at how we can provide a much more accessible service that is not hospital-based, looking at the provision of safe houses, looking at home treatment schemes. The other area, which I do not think has come up this morning is the service to people with less severe mental health problems, those people who actually use services in the primary care field; and one of the things that is going to be developed in Powys is that at the moment we have a number of counsellors in GP practices but there is an initiative to actually put counsellors in all GP practices and to look at developing a preventative service in primary care which will hopefully divert people away from the secondary mental health services but at a much earlier stage than they have been previously. It is those kinds of developments in Powys that we think are very exciting and are very much in line with the National Service Framework for Wales, that we think will be jeopardised by this legislation, because we think that those kinds of initiatives will just go out of the window and we will end up with having to divert all our staff into issues around compulsion and around meeting the requirements of the new legislation. So, yes, the answer is we have.
Q598 Mrs Browning: I was very struck by what you said at the beginning of these remarks on this issue in terms of recognising that a lot of the content of this Bill has been driven by the Home Office, and in our previous evidence sessions it has been very clear that there have been one or two very high profile national cases that have precipitated this. But I have a lot of sympathy with what you are saying; I too represent a very rural community in Devon and I think there is already a tendency to divide mental health services into what locally they describe as core and non-core. I have every sympathy with what you are saying because it is those non-core services, very often the ones that take quite low budget inputs, that actually prevent people then becoming core cases where you go into all the questions of in-patient treatment and everything else. So it seems to me pretty commonsense to look at the so-called non-core cases, but when we took evidence from the Minister earlier she was pressing us to try and influence this Bill in terms of not putting so much on the face of the Bill but leaving more to flexibility of codes of practice, but of course the difficulty with that is that if it is not a statutory requirement the funding does not necessarily follow, so you are caught between a rock and a hard place really. I have a lot of sympathy with what you are saying but I just wonder how you see the balance being struck there in terms of getting more recognition for the non-care services and that very important client group who really need and deserve those services.
Ms Richards: It is tricky, because what you have with people with mental health problems is that you have a huge range of needs, some of which can be met locally, some of which may need the person to go out of Wales into more specialised facilities, and it is a balancing act. The new Oneness Agenda in Wales and the National Service Framework is actually starting to address the mental health side, it is not just about mental illness it is about promoting mental health, looking at early intervention and looking at early access so that in the long run you get health gains from actually preventing people from deteriorating and getting into the secondary care service. But it is a balance, you are absolutely right, you have to provide the services right across the board for a whole range of needs.
Q599 Tim Loughton: Can we change the subject now to the criminal justice system and the interface with the health services in the Bill? This really goes to the apparent schizophrenia in this Bill, as to whether it really is a bill about helping the mental health needs of people through the health service and through social services, or whether it is a criminal justice bill about locking people up in order, supposedly, to protect the public. That is a big enough problem that we have got in dealing with it as it applies to England, but there is an even more confusing situation in Wales because the first of those is a devolved matter for the Assembly, the second of those is not. What added complication is that situation going to bring about, with looking after people in Wales do you think?
Ms Richards: A lot of that has been said this morning by the Minister and by the other Committee members because the National Service Framework is different in Wales, the policy initiatives and priorities are different in Wales and, to be cynical about it, if you have a Department of Health and a Home Office working from London it is much easier for them to get together and maybe put a spin on these difficulties than it is when you have health devolved to an Assembly which is probably out of that loop. Our concern about it is that the public safety driven aspect of it is going to undermine the very collaborative and quite exciting developments that are just about emerging in Wales around the National Service Framework and about the Oneness Agenda, and we think that is going to be undermined by the public safety angle of the legislation.
Q600 Tim Loughton: We had this dichotomy in the Children Bill which has just gone through Parliament and the appointment of an English/UK commissioner for children whose remit is nothing to do with the rights of children and is a very different remit to that of the existing children's commissioner in Wales who will be able to have a more comprehensive attention and duty of care towards the welfare of children outside of the criminal justice in Wales where their rights will not be treated on an equal basis. Do you think that the result of all this will be that more people are going to be picked up in the criminal justice system rather than a proper liaison between police and social services and health as a joined-up approach to really what is best suited to that person's individual needs for their protection before primarily we talk about their supposed dangerousness to the public at large?
Ms Richards: I do not know, but I suspect that might be a possibility, yes. I have to say that neither of us are lawyers, we do not really understand all the clauses and the machinations of the legislation, it is difficult to get your head around it ---
Q601 Tim Loughton: Nor do we.
Ms Richards: But that is an anxiety. Because the definition of mental disorder is so broad within this new legislation it brings, potentially, a lot more people under its remit so potentially all sorts of things, particularly when you are looking at the Home Office driven bit around public safety where all sorts of variations, I think, could come into play. It is almost like a blank sheet of paper in some cases.
Ms Cowie: And there are real fears that the climate that will come out of it will mean that people will be afraid of compulsion and will not seek the help they need early enough, until everything has gone wrong and until, probably, they are leading chaotic lives, not getting the support and help they need and they probably do come under the criminal justice system.
Q602 Chairman: Connected with that can I ask you a question which I think we would like your view on because you both come from the voluntary sector; you are not here either to defend or attack Government and you can perhaps give us a bird's eye view of the future, in a sense. Community Treatment Orders, if enacted, will bring compulsion into the community; can you comment first of all - and I think Ms Cowie may just have answered this question - on the effect that is likely to have particularly on the younger male and female quite severely disturbed and mentally ill patient? Secondly, can you comment on the effect that compulsion in the community will have on such resources as are available and which you see from your Powys Mental Health Strategy viewpoint?
Ms Cowie: We know already that 50 per cent of young people's first encounter with mental health services is under compulsion, when they are detained in hospital. This makes it very, very difficult then to establish a therapeutic relationship of trust whereby they continue to engage with services and continue to engage with the help that they actually need; so this Bill is going to make it much harder in fact to do that work and, in a rural area, we do not have early intervention teams, we do not have home treatment teams. We have a number of users using the voluntary service who have the label "personality disorder", women who self-harm because of a history of sexual abuse, for instance, who are extremely worried by this Bill and extremely worried that they will be under community orders.
Q603 Chairman: The effect on resources?
Ms Cowie: We are very, very worried indeed that in a rural area with such a low base of resources what precious few resources we have got will all be taken up in fulfilling the requirements of the Bill and we will lose what little we have got. Bearing in mind we have no place of safety in north Powys, we have (as you have heard already) only one social worker who has to travel such huge distances, we have to go out of county for a place of safety, we have no section 12 GPs specialising, we really are very, very short of services and so the additional strain is going to suck up the few that we can divert to the voluntary sector.
Chairman: Lady Finlay?
Q604 Baroness Finlay of Llandaff: I apologise if this question puts you somewhat on the spot and I should have probably asked it to both the Minister and our previous witnesses, but you have not advocated anything that I have heard that is positive for this Bill; should this be an England-only Bill and should Wales have its own completely separate legislation?
Ms Richards: Yes.
Q605 Chairman: Forgive me asking for a couple of reasons, or one reason?
Ms Cowie: A lot of people have said that the Scottish model looks good, it meets a lot of the anxieties that people have raised through the consultation exercise and I think that we ought to go the way the Scottish have gone.
Q606 Chairman: Let me ask you something different; if the Bill was in the Scottish form then your answer would be different, would it?
Ms Richards: One of the things that we have recommended in our submission is that this Committee should actually be looking at the Scottish model as an alternative.
Q607 Chairman: I am just trying to clarify whether the answer to Lady Finlay's question is yes, we would like a separate Welsh Bill because we do not like the Bill, or yes we would like a separate Welsh Bill because we do like devolution.
Ms Richards: It is a bit difficult that question; what we are saying is that devolution actually has its advantages in terms of this particular piece of legislation ---
Ms Cowie: We just do not like this Bill.
Q608 Chairman: So it is both, that is fair enough. I am going to ask you this because I think your evidence has been of very great value to the Committee; is there anything you would like to add, whilst you have this opportunity, which you feel needs to be said?
Ms Cowie: If I may I would like to read you a very short piece from a GP in Machynlleth, not about this Bill but we have invited him to a local mental health planning meeting and he cannot make it. "As you know, we have a crisis in mental health. We have only one CPN with an unacceptable workload, there is no official counselling facility for any patients in this area, we have only been given lip service for the past two years to have this. Patients have had upwards of 13 locum psychiatrists in the past two years; both they and I are totally fed up. Patients with alcohol and drug problems have to wait unacceptable lengths of time to be seen because of shortage of staff; in the event that a patient sadly requires a mental health section the approved mental health social worker in theory sometimes has to come from - I think the last time was Merthyr Tydfil. As you also know we have no child psychology service and a long waiting list to see the psychotherapist for adults. The state of affairs really has reached a point where it is dangerous and I worry that we are wide open for potential litigation. I hope your meeting goes well." That is the state of affairs currently, before we have the burden of this Bill.
Q609 Chairman: Do you want to add anything else?
Ms Richards: I was actually going to continue with the point I was going to make about the concern that we have got about Community Treatment Orders in rural areas; I think it could potentially lead to discrimination, and there are differences between an area where you have got the services and you have got the staff and people can actually get the treatment they need without having to use Community Treatment Orders and rural areas, and there is a very real concern that people in rural areas will be discriminated against.
Q610 Mr Prosser: Is it not the case that the Community Treatment Orders are a power and a facility to use or not to use, not something being imposed and directed onto you?
Ms Richards: That is true, but I think there is a lot of evidence to indicate that what really works for people is a good therapeutic relationship, with a good care plan and it is the therapeutic relationship between staff and client that really, really matters. Compulsion to take treatment in a way is almost a situation where that relationship might have broken down, so what we are trying to do is to make sure that treatment is available to people when they need it, with a good relationship, with a good care plan, with good support systems in place and, hopefully, compulsion will not be necessary.
Q611 Mr Prosser: Could not practitioners and people like you continue in that mode without drawing down these extra powers and facilities?
Ms Richards: In the voluntary sector we would not have any powers over the legislation anyway so it is not really directly relevant to our day to day work. In the voluntary sector we work very much with people; a lot of our work is trying to work on an empowerment model, to work with service users so they can influence the way services are evolved across Powys and across Wales.
Chairman: Finally, Mr Hinchliffe.
Q612 Mr Hinchliffe: Some of the most exciting work I have seen in England is being driven by the voluntary sector and I do not know enough about the voluntary sector in Wales to know whether in mental health you feel it has evolved as far as it has within England. Is it comparable to some of the work that I have seen, quite visionary stuff in various parts of England, or do you feel in terms of provision as well that you are some way behind the levels of work being done by the voluntary sector in England?
Ms Richards: We are some way behind, not because of a lack of ideas and good practice but, again, from a lack of money we are some way behind.
Chairman: I am sure I speak for the whole Committee in saying how grateful we are to both of you for coming and giving us such a very good discursive session of evidence, it has been most helpful. I know it will take longer for you to get back to Powys than it will for us returning to London later, but have a good journey. Thank you very much.
Memorandum submitted by Welsh Language Board
Examination of Witnesses
Witnesses: Mr Prys Davies, Director of Strategic Operations, Welsh Language Board and Mr Andrew White, Leader, Health and Care Unit, Welsh Language Board, examined.
Q613 Chairman: Welcome. Can I just remind you of what I have said already, that the session is recorded and that a transcript will be produced within about a week, and you will have the opportunity to correct textual mistakes but not mistakes of substance. Please could you speak up? Would you introduce yourselves, please?
Mr Davies: (Through the interpreter): My name is Prys Davies and I am responsible for language schemes and education policy in the Welsh Language Board.
Mr White: (Through the interpreter): My name is Andrew White and I am the leader of the health and care unit in the Welsh Language Board.
Chairman: Lady Eccles, would you like to kick off here, question 13?
Q614 Baroness Eccles of Moulton: Thank you very much, Chairman. The Mental Health Act Commission in its tenth Biennial Report for 2002-2003 reports a diminishing demand for services in Welsh; if that is the case why should the Government put more resources into bilingual services? That is the main question, but if I could just move on to be a little bit more specific, we have heard quite a lot of evidence this morning about how there is a considerable shortage of resources available to be spent on mental health and we have heard some particularly poignant evidence from our last two witnesses about how very, very thin the services are spread in Powys. This really, I suppose, is a question based on priorities: when there is a shortage of public funding in general in the general budget, is it not right that these resources should be prioritised and that maybe putting further resources into the Welsh language is perhaps not as high on the list as some other needs?
Mr Davies: (Through the interpreter): Thank you for that question. First of all, the question suggests that the Board is asking for further resources in this area; that is not included in our evidence as such, what our evidence suggests is that the policies which are already in place should be implemented, and which are outlined in the Welsh Language Act 1993, that the Welsh and English language should be treated on the basis of equality. Most public bodies working in mental health do have language schemes, they actually implement some aspects of those language schemes effectively and what we do want to ensure is that consistent messages are conveyed from all directions, and that includes from us as the Welsh Language Board and from the Welsh Assembly Government who have emphasised that the choice of language as part of care for an individual is vitally important in care generally and, particularly, in the sphere of mental health. This should be reinforced and there should be an opportunity for this Committee to actually reinforce this. There is something I would like to add to that: we have mentioned that this is something that we want to emphasise and obviously in working for the Welsh Language Board we would do so, but the Welsh Assembly Government have also emphasised the importance of this. What is also important is that the people themselves, those actually receiving treatment, have noted the need for that and a very important report from the Welsh Consumer Council, prepared in 2000 - and there was reference to this in our written evidence - among other things notes that offering a choice of language is not a technical issue, but offering that choice of language is a matter of offering effective care for the patient. If I can quote one section from that Welsh Consumer Council report, the report notes that in the context of mental health patients the pain and serious discomfort caused by mental health can, on occasion, be worsened if the patient is not given an opportunity to discuss his or her feelings and experiences with a mental health practitioner in his or her chosen language. Since achieving the normal balance is the purpose of mental health care then we cannot ignore the Welsh language as a factor if it should be a significant part of the life and mental processes of the patient. So what I would suggest in responding to this point on resources - and we do appreciate that resources are always a problem - offering a choice of language is not a technical issue, it is a matter of offering effective care to individuals.
Chairman: Mr Williams, did you want to come in at this stage?
Q615 Hywel Williams: (Through the interpreter): Some people would say that what is required is a different service rather than an additional service, what I would describe as the Safeway two for the price for one strategy, if you do employ someone who speaks Welsh and English then you have two services available for that one single price. That would then normalise the use of the Welsh language; would you see that as leading to a greater demand for Welsh language service, to respond to the point made earlier that the demand at present is quite low?
Mr Davies: (Through the interpreter): If I could return to the point that demand is low - and that is reflected in the report quoted from in the first question - I would not first of all see that the figures quoted were a strong statistical basis to argue that the demand is actually reducing, it is just a change from one year to the next or from two specific years. Secondly, from what I have read of the report the evidence on demand is based on individuals having to ask for provision through the medium of Welsh, not people being offered that provision from the relevant services. So it is vitally important - and we emphasised this in our evidence - that individuals should not have to request a service through the medium of Welsh, it should be part of the core activities of the services themselves.
Q616 Mr Hinchliffe: I was very interested in your evidence because probably 25 years ago when I was working in mental health services I had the experience of being asked to assist with the compulsory admission of a middle-aged Asian woman who allegedly had been behaving rather oddly; she could only speak a particular dialect of Urdu and there was a male consultant psychiatrist, a male GP, a male social worker, her husband and son were interpreting. Leave aside the gender issues here, forget about those for the time being, I was very disturbed at the situation we were in there where we could not, other than through a member of the family who wanted to see her removed, actually communicate with this particular woman. Without going into the end result, what I would be particularly interested to hear from your perspective is, is there any evidence that you have of that kind of language problem arising currently in mental health services in Wales, particularly where you may have somebody who could be sectioned but is not able to communicate appropriately with the people who are responsible for carrying out that section?
Mr Davies: (Through the interpreter): I am not aware of any specific evidence and I would not expect to hear of specific cases in the Welsh Language Board, we deal with the general policy ourselves and how establishments and functions here in Wales implement those policies. However, the report by the Welsh Consumer Council on the Welsh language in the health service - and I will leave copies with you - does actually follow up the point on the problems which can arise in terms of Welsh speakers asking for mental health services that are not available. This is going back to Hywel Williams' question, perhaps the requirement or the need seems less in terms of the Welsh language but the same is true of other ethnic minorities in Britain. Evidence suggests that people who speak Welsh and ethnic minorities generally throughout Wales use less of mental health services. We do not know the reason for this but perhaps one of the reasons is the perception that English is the language and it is difficult to convey or express complex problems through a language which is not the individual's first language - and there are suggestions of this in the content of this report.
Q617 Chairman: Is your health and care unit able to provide a little more flesh on the bones of the answer that has just been given in answer to Mr Hinchliffe?
Mr White: (Through the interpreter): Again, I am not aware. I am quite new to this post, so please forgive me, but I am not aware of any specific evidence, but I would endorse what was said earlier. The Ethnic Health Unit of the NHS undertook research into ethnic minorities in England and their problems, and Dr Dunesh Bukra from the University of London has compared the situation with the Welsh language and did say that Welsh speakers seem to be following that of ethnic minorities, even in areas where Welsh speakers form a native majority, that is that the expectations of Welsh speakers are the same of services. Also, to look at using services, the problems are the same as ethnic minorities experience in England of course.
Q618 Chairman: What methodology does the Welsh Language Board use to measure the deficit in mental health services in Wales arising from linguistic issues?
Mr Davies: (Through the interpreter): It is not the Board's job to actually assess deficiencies or problems in this area; what the Board actually does is try and ensure that those organisations responsible for these specific areas see it as part of their remit. So what we are trying to ensure is that the organisations are providing services, but also that the organisations are reviewing these services, and the point on providing new functions for CHI becomes vitally important.
Q619 Chairman: I do not much care who collects the information, I am concerned about the collection of the information; where does this Committee find information of a statistical and reliable kind which can tell us in statistical terms - which are sometimes useful - deficits in the provision of mental health services in Wales arising from linguistic issues. For example, how many patients would have preferred to have their initial psychiatric history, which is a key part of any treatment - taken through the medium of Welsh but were unable to do so, issues of that kind. Where do we find that information? If nowhere, why has the Welsh Language Board not used its considerable influence to ensure that that information is available somewhere among the many organisations that govern Wales in one way or the other? I think you are having some help waved at you, a timely wave from behind. Do you want to take the document, then you can give us the answer and we will look it up.
Mr Davies: (Through the interpreter): As I have already noted, what we are trying to ensure is that we work with other bodies and through other bodies and if we cannot show that functions as regards collecting statistics are part of the responsibility of all the organisations providing services to the public, then we would not actually ensure any progress in this area. In response to your specific question we would expect that the National Health Service Unit should collect these statistics, or the providers themselves should collect these statistics. They are things that we ask them to do as part of their language schemes.
Q620 Ms Munn: What we have heard today is that there are significant problems about vacancies in various services; I do not in any way want to diminish the importance of people being able to receive a service in either their first language or their preferred language, and I do not disagree with what Hywel Williams said about buy one get one free, or two for one, if you have somebody who has the ability in both languages. Do you have a view that recruitment of people to these professions who are bilingual is not happening and could happen, and there are sufficient people who have these skills in order to be able to provide that service, or do you take any view on the fact that where you have such severe shortages you actually have to take what you can get, even if that means recruiting people who are from over the border and would be extremely unlikely to have the linguistic skills, albeit that it would be not as good a service for Welsh speakers?
Mr Davies: (Through the interpreter): What we try to do is move to a situation where those bodies who are responsible for recruiting in this area get to know their own needs in this area, and there is certainly a deficiency across Wales. To respond to that, what we ask bodies to do as they prepare their action plans for their schemes, is to find out and to identify where the needs are in those special areas, be it in child care, language therapy and also in the area of mental health. I believe what is happening at present is that we have not reached a situation where we recruit specifically enough for these areas, either recruit or train people, which is another aspect we are trying to develop with the bodies who have actually agreed on their Welsh language schemes. That is one way of developing linguistic ability.
Q621 Ms Munn: I am not clear, are you saying that you think there are sufficient people out there who either have the skills or could obtain the skills pretty quickly, and they have just not been recruited into the service, or are you saying that it is a problem about the service? It is always easy for the service to say well, it would be great if the people who are recruited could speak both languages, but there are not enough of them about, or whatever, without making the effort; what I am trying to get at is whether that is the problem and nothing is being done to encourage people from areas where both languages are spoken, where Welsh is the first language, to actually come into these professions. That is what I am not clear about, and I do not know whether you are saying you do not know because people are preparing this information or whether that is actually the case.
Mr Davies: (Through the interpreter): I do not think we know in enough detail yet what the real need is. As I said, what we try to get from bodies is to get them to tell us what their needs are to implement their language schemes. It is not an easy matter of being able to identify straightaway, for us as a body to say straightaway where the need is we have to depend on the evidence and information we receive from bodies and that has not been sufficiently developed so far.
Q622 Ms Munn: But you are saying that probably the demand for services is under-reported because there is this information which says actually there is not a great demand. You are saying that; you have come to some sort of view that the services are not adequately being provided and therefore it is impacting upon people's mental health, and I think our concern would be if there is a need there how that is being filled. As I say, I think it is very easy for services to say we cannot recruit bilingual speakers and so people who speak only English are better than nobody at all, in which case your field of recruitment is much wider, but do you not even have a feel for that?
Mr Davies: (Through the interpreter): Yes, we do, and to respond to that point I do not think that a number of those bodies who offer these services in Wales have got to grips with this side seriously, so there are deficiencies in the clinical service offered to staff but they really have not got to grips with the question of how to respond to that deficiency, be it trying to recruit specifically for staff - and I do not think there are any cases of them actually doing that - or actually internal training. I hope that answers your question.
Lord Rix: Could I first clear up a point to Meg and to Hywel? The two for the price of one was not invented by Safeway, it is a theatrical term - two for the prices of one ...
Chairman: Tickets to the Whitehall Theatre way back in the Fifties, we know.
Lord Rix: They were known as "twofers" and theatres were known as "twofers", that is where it all began, just to clear that up. Not Safeway.
Chairman: There we are; thank you, Lord Rix.
Q623 Lord Rix: Surely a simple solution, obviously you are going to have to recruit professionals who are not Welsh-speaking or ethnic minority-speaking, but would it not be possible for the Welsh Language Board to have a group of advocates who are Welsh-speaking who could be seconded to the various areas of concern, as required.
Mr Davies: (Through the interpreter): That does not actually fall within our remit, our remit is much narrower than that, we would not employ such advocates to work with the health service.
Q624 Lord Rix: Would it not be possible to suggest then that sufficient funding was made available so that you could run such a service?
Mr Davies: (Through the interpreter): It might be useful if I provided some of the constitutional context here, which is that the Welsh Language Board will cease to exist as a body before 2007 as our functions are being taken into the Assembly Government. That, in one sense, makes it easier to address that particular issue. These are practical issues which you have raised, and it might well be that that would be the most logical way to deal with it so that different bodies work across their particular boundaries to ensure that that service is delivered.
Q625 Hywel Williams: (Through the interpreter): Can I ask whether you as a Board are aware of any organisation involved in psychiatry which actually meets the requirements of the Welsh language as a normal part of their training strategy or as part of their workforce planning strategy, so that recruiting Welsh speakers could be part of normal practice within those organisations. Is anyone in Wales doing that, or are there some organisations in Wales doing that?
Mr White: (Through the interpreter): The health service in Gwynedd is attempting to work in that way; the Gwent NHS Trust has just announced that they have had 30 applications from staff who believe that learning the language is an essential part of offering effective patient care. That has come through from the staff themselves; of course it is the organisation itself which organises the service but the staff are insisting on this training. Providing Welsh-speaking staff or staff with linguistic skills in the workplace as part of the service is about three things actually: recruiting people who speak Welsh, training people to speak Welsh and also, when required and there are not Welsh speakers available, then you need to reorganise the service. There are a great many Welsh speakers working in the health service in Wales, very many, and it would be possible in most cases actually to reorganise services to actually facilitate language choice for patients. That is another point there, but there are a number of examples of that.
Q626 Hywel Williams: (Through the interpreter): If I could just follow up on that with one question, in terms of organising the workforce you will be aware of course that research has shown that those people lower down the scale in terms of power are more likely to be Welsh speakers in the health service in Wales and that people who have the greatest contact with patients are also lower down the scale. So are there organisations in Wales looking towards developing their current workforce in order to give these people different functions, people who have language abilities and experience of contact with patients but maybe do not have the status within the organisations?
Mr White: (Through the interpreter): If I could just ask for a little clarity on that.
Q627 Hywel Williams: (Through the interpreter): What I am proposing is that there is a split in terms of language, culture and linguistic division of labour, if you like. There is some evidence of that, therefore are there internal strategies within organisations to bring these people forward and to provide training for them and to promote their skills so that they then can actually undertake these higher grade functions and can actually work with patients?
Mr White: (Through the interpreter): This is something that has been commenced in local Government and we hope will transfer into the health service within the next year, that is to create a strategy for linguistic skills as part of the implementation of their language schemes, and that deals with recruitment and shift organisation when service is required, also how they are going to develop as organisations in order to provide effective service through the medium of Welsh and English for patients.
Baroness Finlay of Llandaff: I rather hope that you might feel that this is a fair representation, that the medical school here has tried very hard through its widening access policy to reach out and encourage children from Welsh-speaking areas to consider coming into all of the health disciplines, not just medicine, and it has been successful, but we cannot make people take up careers that they do not want and we cannot then make them go into branches of medicine or nursing when they have qualified that they then do not want to go into, and we cannot stop them applying for jobs in England, Scotland or elsewhere as part of their career progression. Therefore, if we go back to looking at what has been done, the lessons in Welsh for staff have been positive in that they enable staff to demonstrate empathy, but the language skills are not enough to be able to take a complex, very subtle, emotionally charged history from somebody who is very distressed because you need a very high degree of fluency for that. Therefore, when we go back to this Bill, perhaps it might be helpful in guidance in Wales to do what some of the cancer services have done, which is identify those staff who are Welsh-speaking and come to an arrangement whereby, if there is a patient who would feel more comfortable communicating about sensitive issues in Welsh, we have a sort of rota system whereby a colleague will come over. For example, in palliative care my colleague in Bridgend would come over to see a patient for us for a sensitive communication on a one to one if that is what the patient would like. That is much more effective than using an interpreter. I do not know whether you also agree that you can have a false sense of security with an interpreter, as has already been outlined, and that actually a rotation between all the staff, identifying who is a fluent speaker - and sometimes not even directly in that specialty ---
Chairman: Forgive me for interrupting, Lady Finlay, but that is quite a long question.
Q628 Baroness Finlay of Llandaff: I know it is, but I do feel that we have really tried within the university to do a huge amount, and I would hate the Committee to have the impression that there really has not been a huge effort to recruit from these areas.
Mr Davies: (Through the interpreter): I think we would be happy to agree with that point. To talk generally about how bodies have looked at their implementation of language schemes within the health and social care sector and more widely, I think it is fair to say that a lot of them have focused on the more technical aspects which is the production of documents and general information and maybe front of house contact with patients, consumers or individuals. I think what we are reaching now is the point where we need to focus more, if we are talking about the health and social care sector, on how we meet the needs of particular patients, how we identify the need and then think about practical measures of putting those into effect, working across boundaries as well.
Q629 Mr Hinchliffe: I am interested in the parallels between Yorkshire and Wales because I can think of some of my constituents who, frankly, cannot understand a word their doctors are saying because they are talking complete gibberish as far as they are concerned. There are social class perspectives here as well as linguistic perspectives, which I think we should also not lose sight of. I wanted to ask Mr White a question because he made a point a moment or two ago about the fact that within the health service in Wales there are substantial numbers of people who can speak Welsh; on the back of the discussion we had earlier on about the approved social worker and whether the role should be broadened out to include other health professionals apart from local authority social workers, would you take a different view to the witnesses we had previously on the basis of that leading to a greater ability to communicate in Welsh to patients?
Mr White: (Through the interpreter): I would want to seek advice from medical professionals.
Q630 Mr Hinchliffe: It is a specialised area, I appreciate that, but it just struck me that the evidence you put forward of the numbers of people in the health service who can speak Welsh might be an argument, if we have a problem with communicating with Welsh speakers, to broaden out the role of the approved social worker to include some of those people.
Mr White: (Through the interpreter): That would certainly be a solution. I would, in terms of its linguistic merits, certainly welcome consideration of that but I would certainly underscore that answer by saying that professional medical and mental health professional advice would have to be sought on those sorts of implications. In addition to that answer and the previous answer, the emphasis should be very much on the patient and not on the member of staff. Obviously, the member of staff is providing a service and we would certainly welcome and congratulate examples of good practice. The vast majority of Welsh speakers and non-Welsh speakers in a lot of the services around Wales have a great awareness of the patient care importance of the linguistic element, and a study on that has just been commissioned by the Assembly; we can leave you with a copy of that. At the end of the day it boils down to the patient and if there are no clinical implications to offering other members of staff, suitably trained but perhaps more linguistically qualified, then we would certainly welcome that.
Q631 Baroness McIntosh of Hudnall: May I make one general observation, Chairman, if I may? Certainly from my own point of view I think the discussion in the last 20 minutes has made me focus on the issue of language and communication in general, rather than simply in relation to the particular issues in Wales, and for that I am personally rather grateful. I wondered if you had any observations to make about how the Bill therefore ought to reflect the particular need for this issue to be taken into account in the provision of services. Do you think there are lessons that you can adduce from your Welsh experience that are more generally applicable and that therefore should not be limited to codes of practice that apply only in Wales? It is a rather unfair question, but I would be interested in your views.
Mr White: (Through the interpreter): I think if the lessons learned in a bilingual nation such as Wales can be applied elsewhere, whether that be in Yorkshire or whether it be in Southwark, I think we would be more than happy for people to use those lessons in terms of the linguistic elements of care for mental health patients.
Q632 Baroness McIntosh of Hudnall: Based on your own experience of how language impacts on the provision of services in Wales would you recommend the Committee to take this issue rather more seriously than just regarding it as a local issue? I am not leading you in any way at all of course.
Mr Davies: (Through the interpreter): I think what I would suggest for the Committee in this area is when considering what appropriate treatment is - and that is going to be one of the aspects of the Bill, what treatment is appropriate treatment - that linguistic considerations, be it in Wales or in England, are a central part of those considerations of what we consider to be appropriate treatment. I am not sure if that has been reflected strongly enough, but there is certainly an opportunity for this Committee to emphasise this in their response to the Government.
Chairman: Thank you very much. You will gather that we have focused on one question and it seemed to me the most pertinent question which required to be dealt with through oral evidence. We have your written submissions, which have been very helpful, and we are extremely grateful for your tolerance, patience and courtesy in dealing with a Committee which is only very partly Welsh. If there is anything arising from what has been said that you would like to follow up, please feel free to do so because we have not dealt with all the questions. Thank you, the meeting is concluded except to ask the members of the Committee to do as we are told in the next few minutes because there are arrangements.