We move on to item 7 on our agenda this afternoon, which is a debate on the Children, Young People and Education Committee's report on perinatal mental health in Wales. I call on the Chair of the committee to move that motion. Lynne Neagle.

Motion NDM6642 Lynne Neagle

To propose that the National Assembly for Wales:

Notes the Children, Young People and Education Committee Report on Perinatal Mental Health in Wales which was laid in the Table Office on 17 October 2017.

Motion moved.

Thank you, Deputy Presiding Officer. I'm very pleased to open this debate on the Children, Young People and Education Committee's report on perinatal mental health. Perinatal mental illness affects up to one in five women in Wales. With around 33,000 births a year, that means up to 6,600 women in Wales encounter mental health issues caused or worsened by pregnancy or childbirth every year.

Perinatal mental illness is not rare, it is not strange and it is not something to be ashamed of. We also learned that it's not only mothers who are affected—partners can also suffer, as can members of the wider family who seek to support their loved ones both emotionally and financially during periods of ill health.

The underlying reason our committee chose to consider this topic is the fact that perinatal mental illness can have an effect on children. It has been proven that the first 1,000 days of a child's life, from pregnancy through to a child's second birthday, is a critical window of time that sets the stage for a person's development and lifelong health. It is a period of enormous potential, but also of enormous vulnerability. A strong bond between a baby and their primary care giver is developed through positive and responsive behaviours. As a result, poor parental mental health can have a significant impact on children's health and development. But it needn't be all doom and gloom. People do come through this. In fact, those who gave evidence told us that, with the right care and support, women can make a full recovery and lead fulfilling family lives. 

So, what did we find? We learned that, for the majority of women, care in a community setting will be the most appropriate. Delivered effectively, it will enable mothers to remain close to their families. Community care can play a vital role in intervening early, preventing the deterioration of mental illness in perinatal mothers, reducing the need to travel for care and alleviating demand on hospitals. 

During the course of our inquiry, we discovered that the £1.5 million invested by the Welsh Government in specialist community perinatal mental health services two years ago is bearing fruit. By now, all health boards have established teams that, for the most part, are operational. However, the evidence we gathered showed that variation in service provision clearly still exists between and sometimes even within health board areas. The support available to women with perinatal mental illness can vary significantly. 

While we commend the efforts that have been made to establish the new teams across Wales and recognise the significant commitment of the staff who are working hard to roll out and deliver high-quality services, we concluded that the current variation is not acceptable. We heard of significant waiting times for certain services, particularly talking and psychological therapies. We also heard of demand outstripping supply. 

We recognise that specialist community teams have only been in place for a short time, and we welcome the progress made to date. However, based on what we've heard, we believe that services in Wales do not currently meet in an equitable or comprehensive way the needs of women at risk of or experiencing perinatal mental illness. We believe that timely and high-quality services should be an expectation and a right for all women, not depending on where they live. As such, we make a number of key recommendations relating to this area in our report. 

Firstly, we recommend that more funding needs to be provided to bring all specialist community perinatal mental health services up to the standard of the best. In recommendation 9, we state our belief that the primary aim for the allocation of this additional funding should be to address the disparity in service provision between health boards in Wales. We are acutely aware of the financial constraints facing the NHS at the moment. However, we firmly believe that an invest-to-save argument can be made for this additional funding, based on the costs of perinatal mental illness.

We were told that, across the UK, for each year of birth, the cost of perinatal mental illness to the NHS is £1.2 billion. The estimated long-term cost to UK society as a whole is £8.1 billion. It should not be a question of whether we can afford to invest in these services, rather, can we afford not to. We note that the Cabinet Secretary has accepted this recommendation in principle, and refers to the additional £20 million allocated to mental health services over the next two years. While we welcome this, we would welcome further assurances from the Welsh Government that this funding will be used to address the gaps in perinatal health services when health boards come to allocate that funding. 

We were particularly concerned to hear about the lack of psychological support across Wales for pregnant women and new mothers experiencing mental health problems. We heard how helpful it could be, whether delivered individually or as part of a group. Recommendation 10 states that the Welsh Government should ensure the work it already has under way on this to improve access to psychological therapies for perinatal women, and men where necessary, is prioritised, given the established link between perinatal ill health and a child's health and development. We welcome the Cabinet Secretary's acceptance of this recommendation, and will follow progress on its implementation closely. 

Unfortunately, for some women, care in the community is not an option. It is estimated that as many as 100 women a year in Wales will suffer symptoms so severe that admission to an in-patient unit will be necessary. Following the closure of Wales's only mother and baby unit in 2013, we heard that some Welsh women were having to travel as far as Derby, London and Nottingham for this treatment and others were being treated in adult psychiatric wards separated from their babies. We concluded that this was wholly inadequate.

While we accept that the most specialist of services will sometimes require patients to travel, our report is clear that mother and baby unit provision needs to be developed in Wales. Recommendation 6 called on the Welsh Government to establish a mother and baby unit in south Wales, commissioned and funded on a national basis to provide all-Wales services and adequately staffed in terms of numbers and disciplines. However, our seventh recommendation acknowledges that a unit in south Wales will not necessarily be suitable for mothers and families in mid and north Wales, for example. As such, we call on the Welsh Government to engage as a matter of urgency with NHS England to discuss options for the creation of a centre in north-east Wales that could serve the populations on both sides of the border.

While we welcome the Government's acceptance of these recommendations, we are disappointed that it still remains unclear what the model of in-patient care in Wales will be, and we are also concerned that the data we requested on the level of demand for in-patient care has not yet been published, and we hope to hear more about this in the Cabinet Secretary's reply to the debate.

I'd like to move on now to discuss awareness of perinatal mental health. It was clear from our inquiry that this remains poor among the public and health professionals. Front-line staff, including midwives and GPs, reported feeling ill equipped to identify and treat maternal mental illness. Therefore, we recommended that the Welsh Government undertake a public awareness campaign to improve understanding of perinatal mental health and the symptoms. We are disappointed by the rejection of this recommendation but look forward to hearing more from the Cabinet Secretary in his reply about the public education approaches he believes will be most effective in achieving the levels of awareness we think are crucial if we are to reduce the high level of stigma reported to us during our inquiry.

The need to improve identification of perinatal mental illness and increase communication between professionals to ensure that vulnerable patients are identified quickly and receive the continuity of care they need were also key themes. We are pleased the Government has accepted in principle our recommendation that every health board should have a specialist perinatal mental health midwife in post to help with this and that health professionals likely to encounter these issues receive pre-registration training and continuing professional development on perinatal mental health, and we look forward to hearing how this work will be taken forward.

The importance of bonding and attachment was a key theme that emerged in the inquiry. We were told that, if secure attachments are not established early in life, children can be at greater risk of detrimental outcomes, including poor physical and mental health and low educational attainment. We are disappointed that the Cabinet Secretary rejected our three recommendations in this chapter. We believe our suggestion of a specialist health visitor with a focus on perinatal and infant health warrants further consideration. We also believe that further consideration of the impact of feeding on perinatal mental health is crucial. The Cabinet Secretary's response that there's currently conflicting evidence in this area is the very reason we called for further work to be undertaken, and we urge him to look at this again.

Finally, the use of medication during pregnancy was a key theme arising in evidence. We believe this is an area in significant need of attention for the benefit of both professionals and patients alike. The final chapter of our report begins a conversation about the link between mental health and health inequalities. It is clear that the perinatal period offers a particular opportunity for safeguarding well-being in the long term. We believe a more concerted effort to reach more vulnerable groups is required and further research is needed to identify the best mechanisms for early identification and treatment of populations in greatest need. We are pleased the Cabinet Secretary's accepted our recommendations and we look forward to monitoring them.

In drawing to a close, I would like to acknowledge the enormous contribution of the charity and voluntary sector in the field of perinatal mental health and in supporting neonatal and bereaved parents. It was clear from what we heard that it is often the third sector that identifies gaps in service provision and goes on to fill them. Without the third sector, many important services simply wouldn't exist. A number of our recommendations relate to this, not least our call for more to be done to provide funding for, and raise awareness of, these services. We think this will enable the statutory and third sectors to join together to provide integrated clinically- and cost-effective interventions. We also echo the calls made by specialist charities for revised neonatal standards to be published. It has taken too long for these to be issued and I want to emphasise to the Cabinet Secretary the need for these long-awaited standards to be published as soon as possible.

I would like to close by thanking all the organisations and professionals who've engaged so actively with this inquiry, but also to thank all those with lived experience who so willingly shared their views with us and whose experiences have been so vital to the committee's work on this. Thank you.

Thank you. Darren Millar.

Thank you, Deputy Presiding Officer. Can I thank the Chair for an excellent opening speech and for doing such a good job of chairing this important piece of work as we embarked on the committee inquiry? Can I also put on record my thanks to the clerks of the committee and the advisers to the committee as well, for their support throughout its course?

As the Chair has quite rightly said, having mental health problems during pregnancy is nothing new: one in five women will experience them. In spite of this, I think we were quite disappointed and disheartened, really, that there was a very low level of awareness amongst some of those front-line members of staff as to what to do when some women were presenting with mental health problems during birth or immediately after pregnancy. That's why I think those recommendations, particularly about upskilling the front-line staffing workforce, having some specialist posts so that they can be a resource to the wider team, are so very important and vital.

In terms of the mother and baby units, there was some debate, of course, about the need for a mother and baby unit in south Wales, but it was pretty obvious that there was going to be a need for one. In respect of north Wales, of course, it is much more complex, because of the sparsity of the population. We were told, as a committee, that the only beds available at present—the nearest ones to those people in north Wales who need them—are over the border in Manchester. But I think it is important that the Welsh Government should actually give consideration to providing resource based in north Wales—which could be accessed by people from the north-west of England—in order to improve access for mothers and babies. Because it was quite obvious from the evidence that we received from mums who'd been there and gotten the T-shirt in terms of poor perinatal mental health, who required an admission into a mother and baby unit, the fact that it was some distance away had discouraged them and deterred them from making the important decision to actually go there, even though all of the evidence that we received pointed very clearly to the fact that there are much, much better outcomes for mums and for their children if a mother is admitted into an appropriate setting in a mother and baby unit rather than in an adult psychiatric ward and is then being separated from their child.

The predictability of the need, we were told by the statisticians, is pretty clear: there are always going to be, based on our population and birth rates, somewhere between 45 and 65 mums per year who are going to require admission into these sorts of wards. Now, because of the population in north Wales, we're talking very small numbers. We're talking a handful, a dozen at most, in the region that might need access to these things, but that doesn't mean that we shouldn't be trying to provide within the region if at all possible. 

I think that one thing that I was pleased that the Cabinet Secretary referred to is that the Welsh Government is making more of an effort to engage with some of the commissioners over the border in England in terms of trying to have a discussion about where it might be possible to base these sorts of services in the future.

Just on north Wales, one of the things that was very striking when we were receiving evidence was the evidence just about the lack of access to these psychological therapies. We've all received an e-mail from Dwynwen Myers, who is one of the perinatal clinical psychologists in north Wales, and she's made it quite clear that she has 18.5 hours per week to cover the whole of north Wales in terms of the perinatal mental health in that region. Much of that time is spent travelling from one place to the next. She gave an example of spending three hours in the car in a six-and-a-quarter-hour day. That is unacceptable. We can't have a situation where people who need access to psychological therapy are simply not getting it. We know that when we nip problems in the bud, sometimes it can resolve things in a way that takes the sting off further down the road. So, I absolutely support the need to spend to save in this particular area in order that we can get things right going forward.

I do want to pay tribute as well, as the Chair did, to the voluntary sector and for the work that they're doing. We had some very moving testimony from women who had been in very difficult situations, some of them at the point of wanting to take their own lives at times, who had searched and scoured their local areas looking for support and had suddenly stumbled upon, very often, local groups, help groups, peer support groups. I think we cannot underestimate their value. I, for one, would very much like to see a mapping of those services across Wales and some seed funding to help them grow and to improve the quality of what they do. If there's one thing that I think would make a significant difference to those organisations, it's just that little bit of seed funding in order for them to grow the support networks that they're able to provide.

So, I congratulate the Chair on the excellent inquiry, and whilst I'm pleased very much with the Government's response, I do think that there are some areas that are wanting in that response, and I look forward to hearing the rest of the debate.

I'll start by echoing the thanks to the Chair and fellow members of the committee, to the clerks, officials and to the stakeholders, who have played a very dynamic role in this debate—more so in this case, I think, than in any other inquiry that I've been involved with. I have to say also that this is one of the most heart-rending inquiries that I have been part of in my time here in the Assembly. Hearing the stories of some of the mothers who were suffering perinatal mental health issues was heartbreaking at times, and hearing those when they were most vulnerable: that they had to decide to leave their children behind to actually access the services that they needed to recover. I can't imagine anything that could make the condition worse than making such a decision under those circumstances. But I do take some comfort, if I may say so, in hoping that this will be one of the most successful inquiries we've held in terms of delivering some of the recommendations made by the committee. I won't talk to soon, but I do think that there are some positive signs in terms of some of the main recommendations made.

Clearly, the first recommendation of establishing a clinical network has been accepted by the Government, and that's something that I warmly welcome. I look forward now to hearing from the Minister about the work that's happened on that front in terms of establishing the managed clinical network and the work of the recruiting a lead role that was supposed to happen during this financial year. So, I would want to hear what progress has already been made on that first recommendation.

Another clear call by the inquiry, as we've already heard, was that for an in-patient unit for mothers and babies. Since the closure of the Cardiff unit in 2013, there has been some debate on the need to re-establish that service. There is a clear recommendation on where that unit should be, but also there is a clear message on the need to provide services in north Wales. As a Member representing the North Wales region, you wouldn't expect me to argue any different case. There are opportunities here—and there are opportunities that we have referred to in other contexts—to develop cross-border services, which don't necessarily mean one-way traffic from people who need a service having to travel to the west of England. There is an opportunity here to turn that around in negotiation with the health service in England to establish a centre in the north-east of Wales, which could then serve a wider catchment area. So, that is something—as the report recommends—that needs to be subject to urgent debate, and I would hope that the Government would pursue that issue.

Of course, along with this inquiry, there was an agreement between Plaid Cymru and the Government, which ensured a commitment to providing specialist provision for in-patient perinatal mental health, and I'd be eager to hear an update in terms of delivering that. I know of the work that WHSSC has been doing in considering the options, and I'd be grateful to hear where we are on that, because time is of the essence in this context. I'm certainly pleased with the role that my party played in ensuring that this service will become a reality in future, hopefully in the near future if possible. Also, the other element in the agreement between Plaid Cymru and the Government was to secure £20 million of additional investment annually in broader mental health services. There is no doubt that elements of that will contribute to much of the ambition in this report, particularly, as the Minister has recognised in responding to the recommendation, in tackling the variation in services between the various health boards in Wales. We heard the term 'postcode lottery', as is heard in so many other contexts, but certainly we now do need to tackle that issue.

Broader workforce training is important, of course—the emphasis we heard from the Chair on investment in preventative factors; that is, investing to save. We heard the figures quoted, not only the cost to the health service, but to wider society. Upfront investment is a way of saving money, and it's not just a matter of saving money, but saving individuals from the anguish and angst that they face where much of this could have been resolved far sooner.

I see that time is against me so I will conclude by referring to the other element, another important factor that is recognised, and that's stigma, which is common to all sorts of mental health problems. I will take this opportunity to remind fellow Members that today is Time to Talk Day, to put an end to mental health stigma. It's very timely, in my view, that we're discussing this today, and I would encourage all Members, as I will do, to take the opportunity to have that conversation with people. It's quite right that we discuss mental health issues, but it's also a duty on us all to do everything we can to tackle all aspects of those conditions, starting with delivering the recommendations of this report. 

Llyr just stole my line. Of course, it's great timing: we are talking about this report on the eve, I think, of Time to Talk Day, because obviously you produced your report in October and then the Government responded in November. So, well done to the leader of the house that she timetabled this discussion for today. 

Having a baby is a messy business. One minute you're a booted, suited woman with a job to go to, and the next minute you're a sleep-deprived milk machine entirely dependent on other people to enable you to begin the lifelong journey of motherhood. And that's assuming you have those support mechanisms, because if you don't, or the support is given to you conditionally or grudgingly or resentfully, the journey is much more challenging. 

So, I think this is a really important subject. I think nobody's mentioned so far that you are, of course, at increased risk of domestic violence if you are pregnant. Those who've been previously abused are four times more likely to be abused during pregnancy than women with no history of violence. Other risk factors of single mothers are lower education, lower socioeconomic status, alcohol abuse and unintended pregnancy. Perinatal mental illness—there's a strong association with domestic violence, both perinatally and during your whole lifetime. They're not necessarily always present. You can obviously have postnatal depression without having an abusive partner. The reasons you've got your depression can be completely unrelated to anything like that. But we have to be aware that there are these risks, and that mothers are really, really vulnerable when they first have a baby. 

So, I think your recommendation 19, continuity of care from a midwife or a health visitor, is absolutely essential. In my day, you had up to 10 days of visiting at home, unless you agreed collectively that you didn't need it because you had good support mechanisms. But these days I know it's not that consistent, and parenting doesn't come with instructions. Mothers desperately need independent professional advice without the emotional baggage you often get from other family members. 

Recommendation 16 feels a bit like groundhog day to me. I'm pleased to hear that Llyr thinks that this is going to be a ground-breaking report, and that we're really, really going to change things, but I can remember discussing this, I'm afraid, a very long time ago. The Edinburgh postnatal depression scale has been around for at least 30 years and it's a really, really simple tool for asking women how they're feeling, which enables you to assess the potential risk; obviously, not losing sight of your ability to observe the woman and ensure that you've understood—. You already know the person, so you're able to also observe whether or not you think there may be depression going on.

But I find it really depressing that we're still talking about the need for midwives and health visitors and GPs and any other health professional who comes into touch with postnatal women to have these skills, and also to actually ask the question, because it is completely essential for safeguarding of the mother and the child that we are asking these questions. Lynne Neagle asked if we can afford not to provide these services, and the answer is that we absolutely cannot afford not to, because of not just the impact on the mother but the impact on the baby. The baby starts communicating the minute it's out of the womb, and, if the mother, who's the main person that the baby's in touch with, is not communicating with the baby, the impact is absolutely devastating. Why would the baby bother to communicate if they're getting no response from the adult? If the adult is utterly depressed, they won't be responding.

So, it's completely essential that we have professionals involved, as well as family members, to ensure that, if the person is perinatally depressed, there are other people around to talk to the baby, because the consequences otherwise are lifelong: the failure to secure attachments, the impact on the infant's social, emotional, cognitive and language development, facilitating development of good mental health in childhood and adulthood—as you heard in your evidence.

I'd be very interested to hear from the Cabinet Secretary about the family resilience assessment tool as a way of complementing the Edinburgh postnatal depression scale, because we absolutely have to ensure that the inverse care law doesn't apply here and that those who most need the services of professionals are getting them. One in five women—that means everybody needs this service and everybody needs to understand that we need to talk to women about their perinatal mental health. 

First of all, I'd like to pay tribute to the women and families with lived experience of perinatal mental health challenges who gave the committee the benefit of their hard-won experience during the inquiry. I was horrified by the stories from women and families, who I cannot help feeling have in some cases been grossly let down—but not by the health professionals who are striving to help women in a health system that clearly needs considerable improvement. I think it's a testament to the tenacity and commitment of health professionals and charities that women are still receiving services despite the difficult circumstances.

The most shocking thing for me was that, despite the significant number of women in Wales who may need in-patient care, there is no in-patient care facility in Wales and there hasn't been any since 2013 when Wales's one and only MBU shut. Since then, the committee estimates that up to 100 women a year have either had to take up in-patient care in England, as far as London or Nottingham, or been treated in an adult unit and separated from their baby. The Royal College of Midwives note that the numbers of women admitted to in-patient care given by the WHSSC would suggest that between 45 and 65 women needing in-patient care are not receiving it. That's an awful lot of women who are missing out on the relevant care. It's a most glaring deficiency to me.

As pointed out in the report, NICE guidelines state that women should ideally be in a mother and baby unit, unless there are compelling reasons for her not to be there. These compelling reasons aren't existing at the moment. The fact that we don't have one—that's not a compelling reason for a woman. Why don't we have one? The reasons for closing Wales's one and only MBU, according to the evidence provided, were: insufficient funding, misunderstanding about who could access the unit, the unit being too small to develop the necessary specialisms and less interest in, or acknowledgement of, perinatal health issues at the time. To me, none of these reasons justified the closure of the unit. The solution to keeping the previous MBU open was in the hands of the local health board and the Welsh Government. In my opinion, they let a lot of women and their families down by closing that unit.

The report refers to a lack of information being provided to women about the benefits of a mother and baby unit, but I would suggest that uptake of in-patient care would inevitably be better if barriers, such as distance or separation from their child, were not there in the first place. As well, I'd suggest that it's pretty pointless advising women about the benefits of in-patient care or a mother and baby unit when the right care is not going to be available to them.

I am, therefore, pleased to note that the Cabinet Secretary has accepted the committee's recommendation that an MBU be restored in south Wales. Whilst I'm pleased that the Cabinet Secretary is developing those plans, it won't be accessible for women and families in north Wales. The report acknowledges that north Wales doesn't have a sufficiently high birth rate to make a north Wales MBU viable, as does the Cabinet Secretary. I note that the Cabinet Secretary has asked the Welsh Health Specialised Services Committee to discuss the options for north Wales, but his detailed response falls short of an undertaking to establish an MBU in north Wales that is accessible to people in north Wales and mid Wales, whether shared with England or not. It appears to be simply a promise to think about it.

Personally, I believe that the proposal for an MBU in north-east Wales, to be shared with England, is an excellent one. The present situation, whereby Wales relies on in-patient beds in England, is untenable. South Wales may get an MBU, but people in most parts of the rest of Wales will still have to rely on Wales's ability to commission beds in England. The WHSSC stated that obtaining an MBU bed is becoming increasingly difficult. This leaves Wales, especially until we have our own MBU, at the mercy of decisions made by NHS England and the demands on those services in England.

The report refers to a hidden demand for perinatal care, and I would like to see the Welsh Government properly address the call by the committee for the Welsh Government to identify the level of demand for an MBU in Wales. I would therefore ask the Cabinet Secretary to provide details about how the level of demand for an MBU across Wales is going to be assessed.

Another point I'd like to speak about is continuity of care. A recurrent theme was that the women needed continuity of care, and we heard that women seldom, if ever, have this. One of the challenges identified during our inquiry was the under-reporting of perinatal mental health problems by women themselves. But, without continuity of care and the ability to form a relationship of trust with a health professional, how is a woman and her family able to feel confident to voice any concerns to those people about how that woman or her family might be feeling? The health professionals themselves have no reference point to assess mothers and offer assistance.

So, the systematic and continued failure of Welsh and UK Governments to invest in training for the relevant professionals has produced this situation. We have failed to train our own staff and now find ourselves being unable to recruit professionals for our own health service. This is denying women the continuity of care and a relationship of trust with a regular health professional with whom they feel safe enough to discuss their mental health.

Regardless of all of that, I am, however, encouraged by the Cabinet Secretary's initial response to the report. I look forward to hearing an update in due course on your progress in implementing the report's recommendations, in particular, recommendation 7 relating to the creation of an MBU in north Wales shared with England. Thank you.

I agree with Michelle Brown that one of the perplexing elements—at least as I found it—about the inquiry was trying to understand why the mother and baby unit that had been operational at the Heath hospital in Cardiff until 2013 closed. I don't feel we quite got to the bottom, at least to my satisfaction, of what the thinking was and what the justification was for why that happened at the time.

It certainly seemed that it wasn't being sufficiently well promoted across the health system in Wales. We found evidence from north Wales of people who actually came, in the end, to that unit and it turned around the situation for them. They were signposted to it informally by people outside the Government and health board-provided system.

It's not ideal for people in north Wales that there aren't enough people there to justify a unit just for north Wales. Perhaps an arrangement could be made with Manchester, perhaps with people from Manchester coming to north Wales for a change or whether people from north Wales do on occasion travel to Cardiff or somewhere else in south Wales—the Royal Gwent Hospital have done a bid within my region and I know there's been a lot of consideration of different specialist services and where they should be going. Despite the excellence of the Heath in Cardiff, I know there are many other hospitals that can ably do this.

I believe the Cabinet Secretary accepts our recommendations 3 and 6. He referred to, and I had to check the acronym here:

'The Tier 4 sub-group of the AWPMHSG is currently costing options for consideration, while considering the concerns raised by WHSSC’s Joint Committee. The options are to be presented to the Joint Committee in January.'

Given that it's 31 January today, I hope the Cabinet Secretary can report to us as to what the joint committee made of those recommendations. I'd just like to emphasise, I think for the committee as a whole, that what we felt was important was that there should be a mother and baby unit. We believe, as I think the Cabinet Secretary does as well, that there is sufficient demand in south Wales to justify one. Given the fixed costs and the necessity of specialist care at that mother and baby unit, it strikes me that that has to be a full mother and baby unit as opposed to a different model of provision that's more localised. I just can't see how that operates on an in-patient basis with specialist perinatal services for mothers, because the demand just isn't sufficient to justify several centres with the level of specialism necessary. So, I hope the Cabinet Secretary will update us on that.

Following on from Jenny Rathbone's remarks, if I understood correctly, I think the reference was to a fifth of mothers needing some potential engagement with mental health services at this stage, and I think you then referred to that being everyone, which I didn't quite follow through on, but it's clearly a substantial number. I think, when you're looking at a pathway or thinking of how the care operates in this area, there are some different categories. There are women who have been in contact with mental health services or have issues perhaps with active treatment at the time they fall pregnant and then give birth—. I give way, Jenny.

Just to clarify, really what I meant to say was that, because it's one in five, everybody needs to be screened. Because the prevalence is so high, we're unable to say this is just a small minority.

I would agree with you on that, and I think the circumstances of birth and the way the health system supports it do allow that. Our baby's now eight months old, but when my wife gave birth in May last year, we were very struck by the quality of the provision and just how much we had in the way of midwife visits and how many interactions we had prior to being discharged from that service. While that level of attention is being given, it is an opportunity to explore these issues to screen. It's sometimes quite difficult to make a binary diagnosis of whether someone is suffering from postnatal depression, for instance, or not, but there are some pointers or suggestions that that is a risk or perhaps that they may be. And I think that, in those circumstances, having a step down and step up to the system, potentially involving the third sector, is very important. So, in some cases, where a baby is discharged but there is thought to be the basis for follow-up, sometimes that will be done through the health visitor but, potentially, also through the third sector, and just flagging circumstances where it's worth that extra bit of follow-up to see if you can catch people. So, you have a group who already are in contact and those who are not.

And then there are the really quite serious things. I was quite struck by postpartum psychosis, and I'd particularly like to give credit to Sally Wilson, who I thought was a fantastic witness who really assisted me in understanding this issue. Simply the extent to which patients can respond to someone from the third sector who's been through that experience themselves is so important, I feel that we need to do more for our health systems to integrate that third sector unique support to give women the support they deserve and need in these circumstances.

Thank you. Julie Morgan.

Thank you very much, Deputy Presiding Officer, for calling me to speak in this very important debate. The Chair and other speakers have outlined the extent of the problem and how it affects the baby as well as the mother and other children in the family.

The issue about the mother and baby unit has been very clearly made. I think everybody agrees. All the speakers who've said anything this afternoon have made the case for having a specialist mother and baby unit, and I'm pleased that the Government has responded well to that. Because we did hear very distressing stories about how the absence of a local mother and baby unit made it very difficult for women who needed in-patient care and actually did have an awful choice of having to go to either adult psychiatric care wards without their baby, or going to a mother and baby unit in England, often very far away.

We did hear from one third sector volunteer who needed help, but her nearest mother and baby unit was Manchester, and she turned it down because of the distance she'd have to travel, which would involve her being away from her family support network. But looking back, she knew that that would've been the best for her mental health. Certainly, what I've felt from this inquiry is the big benefits that can come from in-patient treatment, which I don't think I was aware of before we actually did this inquiry. So, it was awful to think of people missing out on it.

It was disappointing that the mother and baby unit closed in Cardiff in 2013. I was involved, some years before that, in helping to keep it open, but, basically, I think the beds were underused, but that's perhaps because there wasn't a proper understanding of what the beds were needed for. In any case, the clear message from our committee is that there should be a mother and baby unit along the M4 corridor, and that arrangements should be made in north Wales. I think that that is one of our strongest recommendations.

Secondly, I just wanted to refer briefly to the issue that came up about breast feeding. We all know how important breast feeding is to the health of children, but it's also very important to the mother and child bonding process, which, in turn, of course, does help the mental health of the mother. And I am concerned about some of the evidence that we had, which did seem to show that mothers who failed to breast feed and felt they were failures were more at risk of perinatal mental health problems. So, I think that's something that we should be aware of, because I believe we must be doing all we possibly can, as a Government, to promote breast feeding, but, obviously, we did get evidence that, on times, it was very difficult for women and that this can make them more vulnerable. So, I thought that that was a very important point that came up.

I'd like to just add, as a member of the committee, my support to that view, and note that, although the recommendation has been rejected on that count, the Government has undertaken a work stream and perhaps what we need to do is get further understanding of the impact of the difficulties of breast feeding on perinatal mental health.

Yes. Thank you for that intervention. I think that's definitely something we should look at.

I wanted to end, again, echoing the themes that have come up this afternoon about the importance of the third sector and those voluntary groups we met, which, I think, were absolutely outstanding, like what's now called Perinatal Mental Health Cymru but which used to be called Recovery Mummy. It was set up by a constituent of mine, Charlotte Harding, and I know that  the Cabinet Secretary has visited the Llandaff North hub where she operates. She set up the group in response to the lack of services available, and she herself has lived through postpartum psychosis, perinatal anxiety and depression. She has suffered and recovered from alcoholism, self-harm, agoraphobia and had an eight-year battle with eating disorders, and she openly talks about these huge difficulties that she's been through. And now, her organisation is offering a new mums friendship support group, mindfulness sessions, postnatal exercises and also one-to-one support for new dads.

She gave evidence to the committee about what a huge demand there is for her services. GPs are sending people to her, and yet this is a voluntary group, operating with absolutely no money. I think that is one of the biggest issues for me—that people in her position are in the best position to give that individual support to other people, other mothers, but they do need funding to do it. So, I would end, really, with a plea that these unique groups like Recovery Mummy, those are the groups that I think we need to put additional support into and to make them, essentially, a real part of the whole service.

I would like to thank the Children, Young People and Education Committee, along with the Chair, for their work on this inquiry and for the report.

Perinatal mental health problems are very common, affecting around 20 per cent of women at some point during the perinatal period. They're also a major public health issue, not just because of their adverse impact on the mother, but also because they have been shown to compromise the healthy emotional, cognitive and even physical development of the child, with serious long-term consequences. A study by the Centre for Mental Health found that, taken together, perinatal depression, anxiety and psychosis carry a total long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK. This is equivalent to a cost of just under £10,000 for every single birth in the country. Nearly three quarters of this cost relates to adverse impacts on the child rather than the mother. Research undertaken by the London School of Economics in 2014 found that 70 per cent of Welsh mothers did not have access to specialist perinatal mental health services, and Wales's only in-patient mother and baby unit closed in 2013.

As the committee's report highlights, the Welsh Government have invested in perinatal mental health services. The recent injection of £1.5 million has improved access to specialist community perinatal mental health services, but as the committee discovered, there is an unacceptable variation in service provision across Wales. Mothers have a right to such services, and access should not be determined by the postcode. I welcome the committee's recommendations to establish a clinician-led managed clinical network, which will provide the necessary national leadership together with the expertise needed to develop both the perinatal mental health service and the workforce. This is essential if we are to provide a first-class service in every community in Wales.

I also greatly welcome the committee's recommendation to establish a mother and baby unit in south Wales. NICE guidelines recommend the use of a mother and baby unit for in-patient treatment of new mothers. Since the closure of the Cardiff mother and baby unit in 2013 the care for mothers with severe mental health problems has been woefully inadequate, according to the British Psychological Society. The mother and baby unit closed not because there was no need for it; it closed because it was mismanaged. Insufficient funding and mismanagement of beds were some of the reasons disclosed to the committee. It is therefore imperative that we have a unit in south Wales.

I greatly welcome both the committee's recommendations on this and the fact that the Cabinet Secretary has accepted those recommendations. I look forward to an update on progress shortly. This is too important an issue to drag on for months and years.

I would like to once again thank the committee and the Chair for their excellent work on this report, and welcome the fact that the Welsh Government have accepted the majority of the recommendations. We now look forward to rapid progress being made as this year we will see between 3,000 and 7,000 new mothers suffering with a perinatal mental health issue, and without swift and proper treatment, the mother and child will suffer the effects for years to come. Thank you. Diolch.

Thank you. Can I now call the Cabinet Secretary for Health and Social Services, Vaughan Gething?

Thank you, Deputy Presiding Officer. I'd like to thank committee members for their work in producing the report on perinatal mental health, and the Chair for the way in which she opened today's debate. I do welcome today's debate, which reflects how far we have come in recognising perinatal mental health issues. The days when mental health issues in pregnancy and postnatally were dismissed as simply common complaints that would disappear over time are thankfully in the past. There is an increased awareness and recognition that must lead to much improved care to enable us to tackle issues that can have a severe impact on families, as has been set out in today's debate, especially when people can feel at their most vulnerable.

I'm pleased to agree in principle 23 out of 27 recommendations in the report, and I'll summarise some of the action that we're taking that arises from the inquiry. Members will be aware that steps have been taken in recent years to improve prevention and early intervention. So, the all-Wales maternity record, the Healthy Child Wales programme and the new family resilience tool that Jenny Rathbone mentioned are helping to identify early on the additional mental health support new mothers may need. On that particular point, the family resilience tool has been developed with support from the Government, with leadership and with finance, and since October last year all health visitors in Wales are being trained in its use. So, we are looking at—[Inaudible.]—to improve practice and to help families with the greatest need. 

And, of course, the £1.5 million a year of additional investment we've made, putting it into building community services in every health board, has been instrumental in providing support as close to home as possible for more families right across Wales. In some areas, that's led to new community services that are still in their infancy, while others have been able to use the additional funding to expand an existing service.

What is important is that we have both the commitment and the mechanism in place to ensure consistent standards of care across Wales. I therefore welcome the committee's recommendation that we establish a managed clinical network for perinatal mental health here in Wales. That network will be led by a lead clinician to help drive forward improvements, including implementing clinical standards nationally and data collection. It will provide for a more formal governance and accountability, and that work will build on the excellent work done by the all-Wales perinatal mental health steering group. And I'd like to thank those people for their continued commitment to improving access to people who have perinatal mental health problems. The Welsh Government will provide funding for the new network, and meetings have begun between both the Government and the national health service to put this in place from the next financial year. 

The committee report also refers to the need to develop standards and outcomes. And a point made by the Chair and others was that draft guidance for an integrated standards framework for Wales was presented to the all-Wales steering group last week. The pathway and standards will support the delivery of more consistent outcomes for women and their families wherever they are in Wales. That work is continuing to make progress. 

And on training and continued professional development, the steering group is developing a learning and development framework for staff here in Wales. We expect that to be published later this year. The new clinical network will also monitor and identify further training for midwives, health visitors, GPs and other health professionals. And I will also expect that new network to consider how current provision meets the Welsh language needs of the population. 

The committee is, of course, aware of our commitment to provide specialist in-patient care in south Wales. I'm happy to confirm that at the Welsh Health Specialised Services Joint Committee on Monday, health board chief executives supported the need for a mother and baby facility and  asked to be provided with detailed business cases in May of this year. Now, that could an adaptation of an existing building on the NHS estate as an interim measure before longer term options are considered. We will still need to consider how to make sure that a new unit is properly and fully used, because wherever it is located within the south Wales corridor, there'll be a number of women for whom that will actually be quite a long distance. So, we need to think about not just the mother and baby unit as the answer, but as part of the answer in addition to improving our community-based services. 

And I'm pleased that the committee have recognised that whilst there is a case for in-patient provision in south Wales, we can't say that provision in south Wales would also cover the north as well. So, it's been recognised again that there are insufficient numbers within north Wales to sustain a safe in-patient service for north Wales alone. I recognise what the Chair had to say on this point, and I gently say to Members that, for some of the comments that have been made, we're not in a position to compel NHS bodies in England to utilise a north-east Wales facility. There is, however, an ongoing conversation about what we could do working alongside partners in the north-west of England.

And, in fact, the Welsh Health Specialised Services Committee has been working with Betsi Cadwaladr University Local Health Board to explore options just for that—for in-patient care for north Wales residents. I will expect WHSSC and health boards to work together to agree a model for in-patient care at greater pace over the coming months. To give an understanding of the current expenditure: the current cost of placements is forecast to be around £0.5 million this year, and that could be better deployed towards providing services here in Wales. We are, of course, providing an additional £40 million over the next two years towards mental health services, which health boards will use to enhance services in line with the 'Together for Mental Health' delivery plan.

To touch on some of the recommendations that weren't accepted where there is work already ongoing—on breastfeeding, which was mentioned in today's debate, there is a task and finish group that I was pleased to hear mentioned in the contributions from Julie Morgan and Hefin David, and that is looking at breastfeeding practice across Wales. That's due to report in March. It is important that it isn't just an issue for perinatal mental health. There are a number of reasons why we want to better understand how much we currently support women and partners to breastfeed, and the broader environment in society at large, so that women are supported to be able to breastfeed in public in a range of settings. We're all far too familiar with ongoing incidents where people are simply intolerant and expect women to move aside or to be put away from public. I think that is the wrong view. I think, actually, we need to adhere more—. I call for honesty and grown-up measures on a range of health services, and this is absolutely one of them. The whole public needs to be engaged, and it's an entirely natural thing to do, and we need to support women and others to do so. Regarding medication, of course, breastfeeding mothers and pregnant women who require medication should be individually assessed, with a joint plan of care put in place. And it is for those women and their healthcare professionals to make appropriate choices around medication and understand the risks in either providing medication or not doing so.

On the role of health visitors, health boards have put multidiscipline community services in place. And perinatal mental health services have worked with the generic midwifery and health visiting service to raise awareness of the perinatal mental health referral process to try and deliver greater seamless provision postnatally. And as the Chair recognised at the outset, this is a not uncommon feature pre or postnatal, and it is part of what the generic service should be able to deliver and recognise. We will continue to be led by evidence and professional advice about the skill mix of staff that we require to deliver the service that people in Wales require. And it was positive to hear Mark Reckless's comments about his own experience where his family had had a birth here in Wales and the level of service that they received. And we shouldn't lose sight of that. We actually have a lot to be proud of with our midwifery and health visiting teams here in Wales, partly because there is a real thirst within the profession to learn and to improve, and it's a particular feature of our service here in Wales. 

I can see I'm coming towards the time, Deputy Presiding Officer, so I just want to recognise in the final point that the next major milestone will be the publication of the research project into perinatal mental health services in Wales, by the NSPCC, Mind Cymru and the National Centre for Mental Health. That's due to be completed shortly. I look forward to reading its findings, which should give us a clearer picture on how perinatal mental health services here in Wales are currently meeting the needs of families, and also what more we need to do to better understand and meet those needs. 

Thank you. I call on Lynne Neagle, as Chair, to reply to the debate. 

Thank you, Deputy Presiding Officer. I'm going to have to be very quick because I haven't got a lot of time, so I won't be able to respond to everybody's points, but thank you to everyone who's contributed, and it's great to see such a range of speakers across the Chamber on this very important subject. I'll just try and pick up on some of the points from the debate.

Darren Millar referred to the importance of psychological treatments, and that is absolutely key. We had very powerful evidence in that area. And I think it is very important that we remember that the issues that we dealt with around medication could be alleviated by access to psychological therapies because, often, it's medication that is put into the void. Darren also talked about the importance of needing to map services, and the Cabinet Secretary in his response referred to the work that's being undertaken, the research on that, and I think that will be a very useful piece of work going forward that I hope that the committee will be able to return to. 

Llyr reminded us of the timeliness of this debate and the fact that it's Time to Talk Day tomorrow and the issues around stigma that we dealt with, as with Jenny. Stigma was a very clear theme in this inquiry and I think it's important to remember that stigma is a particular issue for women having perinatal mental illness because they are very fearful that they may in a position where they might have the child taken away from them. So, it is absolutely crucial that we tackle those issues around stigma. That was also picked up by Jenny, who also raised the issues around continuity of care, which Michelle also spoke about—again, another very consistent theme in the inquiry. Women are fed up of having to tell the same story to lots of different professionals. It is really important, notwithstanding the constraints that there are around the workforce, that we seek to get that continuity of relationship there, both with midwives and with health visitors. 

Both Mark and Julie referred to the importance of the third sector. And that was, as Julie said, a really powerful piece of evidence, really—that we have these organisations that literally are running based on carrier-bag collections in supermarkets, yet they're having referrals from social services and from GPs, and that simply has to stop. We have to have a system where health boards and other bodies recognise the role that they play and fund them accordingly.

Caroline Jones, in common with a number of Members, added her support for the establishment of mother and baby unit provision in Wales. It is absolutely key and I think that we have to remember that, in addition to obviously being a very difficult time for women, perinatal mental illness is actually a leading cause of maternal death. The consequences of not getting that care right can be very serious indeed. So, we do need to invest in this provision and get it right.

So, can I just close by thanking again everybody who contributed to the debate, including the Cabinet Secretary, all the Members of the committee for their hard work on this inquiry, the committee team who, as always, have been fantastic, and everybody who engaged with us on this important piece of work? We will be revisiting this on a regular basis and monitoring the implementation of this report going forward. Thank you very much.

Thank you. The proposal is to note the committee's report. Does any Member object? No. Therefore, in accordance with Standing Order 12.36, the motion is agreed.

Motion agreed in accordance with Standing Order 12.36.

I now propose to go to voting time. Unless three Members wish for the bell to be rung, I am going to proceed to call the vote. Okay.