The following amendments have been selected: amendments 1 in the name of Rebecca Evans, and amendment 2 in the name of Darren Millar. If amendment 1 is agreed amendment 2 will be deselected.

I move on now to item 8, the Plaid Cymru debate on mental health services. I call on Rhun ap Iorwerth to move the motion.

Motion NDM7289 Siân Gwenllian

To propose that the National Assembly for Wales:

1. Notes the concerns about quality of care raised by relatives of Welsh patients in inpatient mental health units in England.

2. Believes that no patient experiencing mental health problems should be sent to units that are large distances from their family.

3. Calls on the Welsh Government to:

a) ensure sufficient inpatient capacity for mental health services in Wales so that the outsourcing of care can be phased out;

b) have a plan for the repatriation of Welsh patients currently living in units in England;

c) place a ban on the Welsh NHS using units in England that have poor reports from the Care Quality Commission;

d) ensure that units outside of Wales receiving Welsh NHS money comply with Welsh inspection requirements.
 

Motion moved.

Thank you very much, Chair. This brief debate links very neatly with the debate that we've just had—I'll explain more about that in a few moments. But, it's a debate on a very specific issue that is of great concern to us on these benches, and I hope of concern to us as a Senedd, and to far too many of our constituents too. We are talking here about the high number of patients from Wales who are sent to mental health units that are a long distance from their homes, very often over the border in England. And there are grave concerns about the principle of sending people a long way from home. There are specific concerns about the quality of the care that is provided in many of these units.

There is an example here: Wayne Erasmus claims that he has not been able to speak to or see his autistic son for over three years. His son is living in a unit that has been the subject of a shocking report by the Care Quality Commission, a unit that has seen the use of physical restraint increasing. Another patient from Wales with anorexia is in the unit. She is allowed only three phone calls of 10 minutes per week with her relatives at home, and there are restrictions on what they can discuss during those calls. Does that sound acceptable to you? There are a number of similar cases that have arisen.

But even if there weren't a concern about the quality of the care provided, there is a very important point of principle about the impact on the well-being of a patient of being many hours and many hundreds of miles away from home, not being able to communicate with relatives, often not knowing how long they will be there, and certainly feeling very isolated from those care networks that are so important to people. I remember a constituent telling me how he was taken from his home in the middle of the night, whilst he was facing an acute mental health episode, and taken in a vehicle to the outskirts of London, and how that had had such a detrimental impact on the mental angst that he was already suffering at that time. That can't be acceptable under any circumstances. 

It would be one thing if these kinds of cases were rare, but they're not. Hafal, a group doing laudable work in mental health, mention a survey over a period where they couldn't fill the beds that they had in their unit in Pontardawe, where 30 per cent of the 1,000 people who were part of the study were placed in hospitals in England. There is no sense to that. 

In linking it back to our previous debate, it's important to highlight the fact that Wales doesn't have an eating disorder residential unit. It was a pleasure to have a conversation with a young woman who's a constituent of mine in the meeting today. It was wonderful to speak to Sara about her experiences, and it was heartbreaking, hearing about Sara's experiences. She had to travel a very long way from home to England in order to access treatment, and she was only a teenager at the time. That's unacceptable. 

Let's also consider the closure of the mother and baby unit in Cardiff for mothers suffering postpartum psychosis—a decision that did serious damage, as was clearly stated in the committee's inquiry here in the Senedd. Here's a quote from the Royal College of Psychiatrists:

'People with mental health problems being sent out of the area, out of the country, even, are not people with very rare or unusual conditions. They're people we could care for near their families and near their friends.'

You hear the argument being made sometimes that the critical mass of population doesn't exist here in Wales, but for most conditions, we certainly do have a population that desperately needs that care close to home. It's poor historical patterns in terms of the commissioning of care that has placed us in this position. So that's enough of the excuses; let's send a very clear message that this has to end, and that we have to develop a health service that truly suits our needs as a nation. 

I have selected the two amendments to the motion, and if amendment 1 is agreed, amendment 2 will be deselected. I call on the Deputy Minister for Health and Social Services to move formally amendment 1, tabled in the name of Rebecca Evans.

Amendment 1—Rebecca Evans

Delete all after point 1 and replace with:

Calls on Welsh Government to:

a) ensure that distance from home is considered as a key factor for people who require specialist mental health in-patient support        

b) ensure robust arrangements are in place to monitor the quality and safety of placements in units in England, including collaborative working with the Care Quality Commission. 

Amendment 1 moved.

Formally. 

I call on Angela Burns to move amendment 2, tabled in the name of Darren Millar.

Amendment 2—Darren Millar

Delete point 3 and replace with:

Calls on the Welsh Government to:

a) ensure all Welsh medium and high security mental health patients are placed in Wales unless in exceptional circumstances;

b) ensure sufficient medium and high security inpatient capacity for mental health services in Wales so that the outsourcing of care can be phased out;

c) ensure that Health Inspectorate Wales and the Care Quality Commission collaborate so that mental health units outside of Wales who receive Welsh patients are complying with inspection requirements;

d) introduce Senior Responsible Officers for medium and high security Welsh mental health patients to enable joint working between Welsh Health Specialised Services Committee and local health boards with a focus on the patient; and

e) ensure that communication plans must be put alongside treatment plans for medium and high security Welsh mental health patients to manage the expectations of the patient, their families and clinicians.

Amendment 2 moved.

Thank you very much, acting Deputy Presiding Officer. I am going to talk at speed, because I have a lot to say on this subject and I've only got three minutes. First of all, I'm not going to let you get away with your cheeky little comment there, Rhun ap Iorwerth. You know that these benches care a lot about this, because I have been very vocal on this subject, and I'm very glad that the Health, Social Care and Sport Committee are going to be looking at this very subject.

The reason why we have tabled our amendment is because, actually, we've done enough work to be able to drill down on some of the detail that we need here, Minister. But before I start on that particular element of the amendment, I just want to recount something to everyone in the Chamber. Literally, two months ago, I went to visit one of my constituents in a medium-secure unit in England. It is one that has got some serious Care Quality Commission black marks against it, and whether or not it is good or bad, I can tell you now that, as another human being walking into a medium-secure unit, my heart almost failed me. It is grim. I've also visited prisons. Where would I rather be—a prison or a medium-secure unit? I'd rather be in a prison. If you're in a prison you get to do things. If you're in a prison, you're allowed access to people. If you're in a prison, it's easy to see your family and your friends in specialised waiting rooms. If you're in a prison, above all, you know when you're going to leave. It may be three months, three years, 30 years, but you have an end goal. You don't have any of that optimism, any of that aspiration, any of that certainty when you're in a medium-secure prison. And when you're in a medium-secure prison that's 200 miles away from your family, then the heartbreak is multiplied, because it is very difficult to maintain communications.

One of the things that gets thrown around a lot is that, as soon as you're in one of those kinds of places—and don't forget, if you have mental health issues and you're in a medium-secure unit, you are very often with people who are there through the Ministry of Justice system, and that's a tough call. I saw some tough activity going on. I would not like to be there. 

So you're already a vulnerable person and you're put into a place that makes you even more vulnerable. A lot is made of the fact that we don't have the capacity here in Wales, and we don't, but when you're away, everybody needs family or friends, or an anchor. That anchor is so important. It is the way you find your way back to good health. If your anchor is 200 miles away or 300 miles away and you can't access that anchor easily, then it is very difficult to find your route home. So I absolutely urge the Welsh Government to have a look at this and to have a look at how we provide medium-secure units in Wales. 

Please, with your indulgence, I just want to address points (d) and (e), because a senior responsible officer is absolutely critical, Deputy Minister. One of the big problems you have is that a health board will say, 'This person needs medium-secure provision.' The Welsh Health Specialised Services Committee will then go and commission it and then, between the two of them, there's no clear line of sight on that person, on their progression or on their treatment plan. And, of course, people get moved around. Every time you get moved around from place A to place B, then you are re-reviewed, re-analysed and a new treatment plan is put into place. It's very hard to make those steps going forward; it's always two steps forward, one step back. 

Finally, a communications plan. That is absolutely key, because a lot of the conflict that we see is because family and friends are not given clear communication as to what is happening, what the next steps are and what part they can play in helping that person get better. And the person in there doesn't have a clear communication plan. They immediately feel that they're at the mercy of the people in charge of them, and that, in my experience and for all the people I've seen, has been one of the biggest sources of conflict. So I'd like to see a senior responsible officer and I would like to see clear communication plans laid out with the nearest and dearest alongside the treatment plan, and of course I want to see medium-secure units here in Wales. It's ridiculous having to travel so far away for treatment that should be normal in our NHS. 

Thank you. I call on Mark Reckless. 

Diolch. I'm very pleased to hear from Angela again. I remember her being very persuasive in the Chamber before on this and I know the particular case she's had and the extraordinary work she's done as an AM to support that family. I was also quite struck by a recent tv documentary in the same area. Just looking at that facility, it was so much more prison-like than I had imagined. She says we should have a medium-secure unit in Wales—yes we should. I hope it will be better than what we've seen, at least of some of those units in England. But I don't think it will necessarily mean that it would treat every patient in Wales where we need this mental health in-patient treatment. I think there is a danger in going from specific concerns about cases we're aware of to general but highly prescriptive requirements that we see in this motion.

I just have some concern about saying, too, that no patient should be a long distance from their family. There may be some mental health conditions that are so specialised that there can only be one or two places in the UK where you can give treatment at sufficient scale with sufficient specialists to do it. It may be, in some cases, the right thing for a particular patient in Wales to attend there. I also think there's a potential contradiction between no patient being a large distance from their family and then repatriating all Welsh patients—not clear how defined—who are currently in units in England. Perhaps some of those may have family or support in England, and we have many people who live near the border, and have mobility to move from England to Wales. And there may be special cases for individual patients, and we have to consider those, too. 

I think 3 (c) is too strong in terms of a ban on Welsh units using ones in England that have had a poor inspection. Perhaps they're dealing with that poor inspection, or perhaps that poor inspection was particular to one aspect of that facility. In 3 (c), the Plaid motion puts a lot of emphasis on the Care Quality Commission in England, yet then in (d) says that we should ignore that entirely and they must abide by Welsh inspection requirements. I think that's unrealistic in another context. We can't really have extra-territorial regulation. [Interruption.] Yes, I will. 

Thank you very much. I just wanted to let the Chamber know that I had a meeting with Healthcare Inspectorate Wales on this issue, with the head, and she was quite clear about the difficulties—the legislative and practical difficulties—of monitoring a placement in England from a Welsh organisation.

There are difficulties in monitoring, and we should take those into account, but I don't think that the way to deal with that is to extend the Welsh regulation to English facilities, or think that that's a realistic way of dealing with that. I think that we need to have mutual recognition or equivalence of that, and trusted relationships with regulators.

I'm not convinced about the proposal for a communication plan, but I think that the treatment plan should consider how to communicate with family and others. I think that when we do have patients in England, those facilities in England need to understand who they are dealing with in Wales. I think that there has been a terrible problem with the health board, and then WHSSC, and not being clear who is doing what. We need to be clear, and we need to make sure that the facility that we're commissioning in England is also clear. I think that the Welsh Government have a good amendment on this with the right balance on their points (a) and (b), and we intend to support their amendment, but oppose the motion and the other amendments. Thank you.

I'd like to talk about the experiences of a specific group of people who are suffering from having to go to England to receive mental health care, and that is new mothers who suffer from mental health problems. According to the Maternal Mental Health Alliance, these women are missing out on potentially life-saving care because of the lack of a specialist support unit in Wales. I believe that the first person to call for a specialist unit to be developed was my predecessor, Steffan Lewis. He was successful in playing a part in achieving a commitment from the Welsh Government to develop a permanent unit by 2021, as part of the 2018-19 budget deal between Labour and Plaid Cymru.

Now, we know that it doesn't look like this is going to happen, with Labour set to break a budget deal promise by opening an interim unit within a psychological hospital instead. That is not what was agreed, and it's not what's needed. Breaking a budget deal commitment is a very serious matter, not only in terms of political trust but, more importantly in this instance, it means that new mothers will continue to be denied the treatment that they need.

I'd like to place on record my thanks to BBC Cymru Wales for the excellent journalism that they've done over the past few years, giving a platform to some of the women who have been affected by this. One new mother who was treated at a psychiatric unit—a setting deemed inappropriate for the condition, according to experts—told the BBC reporter:

'I was not in an appropriate environment…there was absolutely no provision for my partner and son to visit during the day.'

Again, we're talking about women in a very vulnerable condition, when they need their families more than ever.

Postpartum psychosis, on the CYPE committee—. When we looked at this, we spoke with one lady who had come down to Cardiff when the facility was there, who would have preferred to go to Manchester. For many in north Wales, it works to go to the mother and baby unit and a hospital in Manchester, and that will be preferable to being made to come down to Cardiff, further from their families.

I accept that in some instances, that will be the case, but there will be many instances where this is needed. Again, I come back to the fact that this was a budget commitment, and this was something that was agreed between the two parties. I accept what you are saying in some instances. 

Another mother said that she went from being really happy to having a baby to not really knowing where she was, and that she didn't know what she was doing and felt very scared and not knowing where she could go for help. She said about her family:

'They weren't allowed to come to my room, we used to spend the time wandering the hospital corridors.'

A perinatal nurse explained the effect that travelling to a specialist unit had on another:

'It took them 10 hours to get there...it was horrendous because you have to stop with the baby every two hours because it was a new born…they got there at 10 p.m....what a terrible thing to do to that woman who was psychotic.'

Experts are agreed that opening a unit in Wales is essential. Dr Witcombe-Hayes of NSPCC Cymru has said:

'It is vital that Wales has provision for a mother and baby unit for women experiencing the most severe conditions.'

According to the Welsh Health Specialist Services Committee, women now face a choice between receiving in-patient care more locally, but being separated from their infant, or remaining with their infant in a specialist unit, but needing to travel away from their support networks. They add that, in many cases, women choose to access local acute psychiatric services that are not fit for purpose and lack specialist knowledge. This is not a choice anyone should have to face, especially not mothers in a crisis situation.

So, to close, the message to the Welsh Government is this: these women need this specialist support unit. The experts agree. You promised to provide it. Please get on with it before any new mothers have to suffer because of this scandalous inaction.

I call on the Deputy Minister for Health and Social Services, Julie Morgan.

Thank you very much, and I think that the examples used in the debate have been very powerful and illustrate the issue that we are addressing here today. And I do recognise how difficult it is for patients and their families when care has to be accessed away from home, and it's obviously much more difficult if families have concerns about the quality of the care being provided. So, I'm pleased to have the opportunity to restate the Government's recognition of the importance of continuing to improve mental health services, including mental health in-patient provision. And I also want to provide assurances regarding the arrangements we have in place to ensure the quality and safety of care for Welsh patients receiving care for their mental health needs outside of Wales. 

Our aim is to provide mental health care closer to home and to reduce the need for in-patient support. Our sustained investment in mental health services, which will rise in 2020-21 to £712 million, is improving outcomes. For instance, the investment in community services has led to a reduction in mental health hospital admissions over time. And we also do continue to see a reduction in the number of patients who are placed in units in England. In 2018, it was 130 and in 2019, it had gone down to 96, and we hope that this will continue, this downward trend. 

But whilst our focus is on providing more support in the community, specialist in-patient provision will always be required to support people with high needs. And whilst we do provide in-patient support here in Wales, we do, in fact, have two NHS medium secure units in Wales, Tŷ Llywelyn in the north and Caswell in the south, we also provide access to support units in England. This allows patients in Wales to access very specialist support provided in units for the whole of the UK. But we do acknowledge that it is difficult for patients and families when they are placed a long way away.  

Minister, will you take an intervention? 

Yes, certainly. 

Sorry, just to illustrate your point because, yes, there is the Caswell Clinic but, actually, they're full already with people. We've got 61 people at my last count, which wasn't very long ago, in England. For example, one of my constituents, because the ward that that person is on is under threat of closure, is now being threatened with a move to Stevenage. To be honest with you, I'm not actually sure I know where Stevenage is, but further and further away from Wales, and they can't get to the few places that we have that are medium secure. We have at least 61 more people who need that kind of support. 

Yes, and I wanted to make the point that we did have the units in Wales; that's the point I was making. 

And when a patient's mental health needs are best met in a specialist unit, health boards are looking at the quality. Firstly, decisions are made on the quality and type of specialist care provided to ensure it meets the needs of the individual. Secondly, the commissioner considers the distance from home and any potential impact this might have on the outcomes for the individual. And the final consideration will be the value or overall cost of the unit. So, quality, distance and value in that order are the key factors considered when placing people outside of Wales for specialist mental health in-patient care.

And when patients are placed outside of Wales, consideration is also given to ensure families and relatives can maintain contact whilst their loved one is cared for away from home. I know comments were made about individual cases, which I obviously can't comment on, but those are the procedures that take place. That issue is looked at when placements are made.

We do have arrangements to ensure the quality and safety of the care provided in the specialist units outside of Wales. The NHS Wales national collaborative framework is a formal agreement and mechanism, developed by the NHS Wales collaborative commissioning unit and NHS Wales. It enables all parts of NHS Wales to procure and performance-manage services under pre-agreed standards, costs, terms and conditions. Placements under the national collaborative framework in healthcare settings outside Wales are overseen by the NHS Wales quality assurance improvement team. This provides assurance to health boards and the Welsh Health Specialised Services Committee that services are being provided in a safe and high-quality environment. 

The NHS Wales quality assurance improvement team also continues to work closely with regulators in England, including the Care Quality Commission. This was the case with the recent suspension of some of the units at St Andrew's Hospital in Northampton. Tripartite meetings between the CQC, NHS England and NHS Wales continue on a monthly basis about the provider.

We published the third and final 'Together for Mental Health' delivery plan in January, and that set out the actions we will take with our partners over the next three years to continue to improve mental health and well-being. The new delivery plan makes a commitment to undertake an audit of current secure in-patient provision, and to develop a secure in-patient strategy for mental health. We are aware of the difficulties that there are. We have committed to commission an independent evaluation, to look at our progress since the publication of the 'Together for Mental Health' strategy in 2012, which will inform our future direction.

And to address the point made by Delyth Jewell, so powerfully—and I was on the committee when we looked at this issue, and we're aware of the huge emotive issues affecting mothers and newborn babies—the Welsh Health Specialised Services Committee has been asked to establish mother and baby provision in Wales to enable mothers to access more intensive support when needed. We recently asked them to urgently explore interim provision while longer term arrangements are put in place, which will be located at the Tonna Hospital site, and are expected to be in place by spring 2021. So, again, there is a plan. We will be providing that. And I just want to reiterate how we are—

The Deputy Presiding Officer took the Chair.

Will you take an intervention, Deputy Minister, or are you out of time?

Yes, certainly. Well, I'm just about to finish.

Go on, I'll let you—. She is out of time.

Thank you, Dirprwy Lywydd. I was just going to make the point that whilst welcoming, of course, the interim mother and baby unit in Tonna, Tonna is four and a half hours away from mothers in the north of Wales. Would you agree that we need a bespoke solution for the problem in the north-west in particular? I think the health board is willing to start discussions around that with a view to getting provision in the north as well as in Tonna.

Certainly, the Tonna Hospital site will not be suitable for women coming from the north, so certainly that's got to be looked at.

So, in any case, I hope I've been able to provide some assurance that we do have plans to look at this whole difficult area, but improving mental health services is an absolute priority for us, and we do have arrangements in place to look at the quality and safety of placements in units in England.

Thank you. Can I call on Llyr Gruffydd to reply to the debate?

Thank you very much, Deputy Presiding Officer, and thank you to everyone who has contributed to this valuable debate and raised very valid and important issues, and particularly the referrals to some of the appalling examples that I fear we're becoming far too used to.

I'll just add one further element to this debate too, in concluding, because last year I asked Betsi Cadwaladr how many mental health patients were being sent to hospitals in England and, of course, there are dozens who leave north Wales for homes and mental health units across England. In many of these, the care provided is appropriate, although it is further from home than any one of us would want to see. But according to the Care Quality Commission, which assesses care standards in England, many of the units where patients from north Wales were sent were either inadequate or requiring improvement. Betsi Cadwaladr health board spends millions of pounds on mental health services and much of that goes to these institutions in England. I have a very grave concern about the level of care provided in these few institutions. It does pose a question as to what oversight there is of those most vulnerable patients if they are many hundreds of miles away from their families, and indeed hundreds of miles away from the health board that places them at those locations.

Two care homes in particular—Cygnet Health Care's Wyke in Bradford, and Partnerships in Care's Kneesworth site—were listed as inadequate by the CQC after its inspection. A further three were found to require improvement. And these are serious failings. Wyke was deemed to be inadequate when it came to safety, effectiveness, caring and being well-led. And in terms of safety, that meant patients were put at risk in terms of monitoring and managing medicines. Now, I question whether the health board was aware of that, and if it was aware of that, well, clearly, there's a question to be asked as to why those patients were being sent there. Now, as I said earlier, even if the services are or were adequate—

I'm sorry, would you take an intervention?

I will, yes, although I'm already over time.

Well, I was just going to say that I can partly answer that for you, because it's deemed, to be frank, second-class citizenship, because there is no other alternative. There's nothing in England that they can go to, and I've met some great people who are very well aware that the settings are not appropriate, like the ones you've just mentioned, but they have no other alternative, because we have nothing in Wales and there's nothing else in England, apart from places even further and further away. And it's a shame because we wouldn't treat people with cancer or heart conditions in the way that we treat people with mental health issues. 

Thank you for that. And, also, of course, it reminds me of another point, in that why is it always one-way traffic? When we want to access services, we have to go to England. Why don't we have the aspiration to actually develop some of those specialisms here in Wales, so that people in England come to us? It doesn't have to be a one-way street. Now, I appreciate sometimes it may need to be, but not always, not always. And this motion is our opportunity to send a clear message in that respect, and I would urge all Members to support Plaid Cymru's motion. 

Thank you very much. The proposal is to agree the motion without amendment. Does any Member object? [Objection.] Therefore, we defer voting until voting time. 

Voting deferred until voting time.