Well-Being of Future Generations (Wales) Bill

Comments from the Directors of Public Health to the Inquiry by the National Assembly Environment and Sustainability Committee

1. The Bill represents a very exciting, timely, though challenging opportunity for the NHS, the wider public sector and the population of Wales to address the complex long term challenges facing Wales – inequality and the unequal distribution of access to resources, benefits and opportunities. It supports the development of medium and long term strategy and there is a clear role for “system leadership” and public health advocacy by the health boards in the geographical areas they serve.

2. We support the merging of the Local Service Boards into Public Service Boards, so as to enable co-terminosity with health board footprints.  We believe this would be a positive move and enable stronger commissioning and planning discussions. In some health boards partners are already moving at a pace to transform the well established Local Service Boards into the new Public Services Boards, with the work of the health boards being aligned with the LSB Single Integrated Plans. We are confident that the Public Service Boards will add strength to senior leadership across the public sector. Clarity is needed to ensure the public health voice is present on the PSB. The health boards all have a DPH and public health team in place to be the link to central services in Public Health Wales.

3. We welcome the fact that the Bill is consistent with and supports the application of the principles of Prudent Healthcare laid out for the NHS by the Minister for Health and Social Services.

4. We welcome the opportunities through the Bill for improving the ways in which we work together with our local public sector partners. The explicit requirement for shared statutory responsibility (para 66) for achievement of the well-being goals across partners, we believe, is particularly important as it will substantially help in our ability to both hold to account, and be held to account by, our partners for a range of actions which promote population health improvement.   We welcome the move to reform integrated community planning and simplify the system, removing the need to develop separate plans for aspects which can much more efficiently be addressed together.  We note that there will remain a tension, however, between planning cycles given the focus on 3 year planning within the NHS and the different national and local political cycles. Whilst not insurmountable, this will add complexity.

5. Acknowledging that the impact of the Commission on Public Service Governance (The Williams Review) on local government structures is not yet clear this will have a major impact on how the public sector locally is able to respond to the opportunities offered by the Bill. We note the reference in the Bill to the definition of communities as areas within a local authority area which are large enough to show differences between them and have a sense of identity but not as small as electoral wards (para 209).  We recognise and welcome this as a reasonable definition but would also stress that there is a considerable challenge in getting to the point at which such communities will be identified and are recognised both by themselves, and by the bodies within the public sector which serve them. Work to address this will need to begin sooner rather than later.

6. We welcome the 6 well-being goals but it is difficult to see how the bill can be legislatively enforced.  We see opportunities to strengthen the Health Impact Assessment approach as part of the process and there may also be merit in considering a gateway type process going forward, rather than a simple checklist approach.  This would allow greater scrutiny at all levels and by all sectors.

7. We believe it is particularly important that we do not fall in to the trap of “disaggregating” the 6 Well-Being goals and seeing our NHS responsibility only related to the Healthier Wales goal. It is of fundamental importance that all partners recognise that all 6 Goals contribute equally to the overall sustainable well-being of the population, and that each contributes to the delivery of the others. The description of this interrelationship in paragraph 127 is very helpful in this respect. We would suggest that such a presentation in relation to the other goals would be very helpful in underlining the fundamental importance of this interrelationship.

8. It is important to note that the Common Aim as described in the Bill through the term “social, economic and environmental well-being” implicitly encompasses health in its widest definition as, for example, defined by the WHO.

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

9. We welcome this broad view of health.  It is our experience that using the term “well-being” to describe our joint working with local partners avoids the difficulties which can arise from using the term “health and well-being” when health is seen as “the business of the NHS”.  The significant austerity colleagues in local government are now experiencing has the potential to exacerbate the perception that health is what the NHS is responsible for (and should, therefore, pay for) and so we are comfortable with the definition in the Bill. 

10. However, we also recognise that there is a considerable risk that not including the term health in the Common Aim could fail to capitalise on the opportunity to embed “good health at the centre of the Wales we want” – as articulated by Welsh Government in its explanation of the narrower focus outlined in the Public Health White Paper.  Without an explicit reference in the Common Aim, other interpretations of the purpose of the Bill could easily be made.

11. The absence of this from the Bill, and also from the Public Health White Paper, means that there is a missed opportunity to secure the wider adoption of Health Impact Assessment as an essential part of all local and national policy development, and a requirement in significant developments.  We would strongly advocate that including this within the Bill would considerably strengthen the likelihood of ensuring explicit consideration of the impacts on the healthier Wales as envisaged in the Well-Being Goal.

12. We welcome the inclusion of the statutory basis for sustainable development as a central organising principle.  

13. We welcome the inclusion in the Bill of the outcomes based approach. We believe that this has much to offer in terms of clarity about what needs to be done and by whom. Again, this is an aspect which resonates across the public sector, although we acknowledge that we have more to do in the NHS in terms of its application. 

14. We welcome the recognition in the Bill that it will be essential for individuals, societies and organisations to commit to make changes now to manage the future challenges that we face (para 10). However it is essential that it is recognised that the ability for individuals to make choices and adopt particular behaviours is very much a product of the circumstances in which they live their lives.  

15. Our reading of the material in the Regulatory Impact Assessment suggests that there may have been a significant underestimate of the amount of work all public bodies will need to undertake in order to fully exploit the opportunities envisaged by the Bill.  This comment particularly relates to the calculations presented regarding the costs of undertaking needs assessments. However, we would acknowledge that this section was complex and challenging to follow, and it may be that we have misinterpreted what was presented.  We do not believe this has a material bearing on our views of the Bill itself but it will be important that in further discussions on the implementation of the Bill a realistic assessment of the capacity and time needed to develop local responses will need to be made with local partners.

16. We believe it is vital to recognise that the change in culture and approach which will be required in order for the public sector to truly embrace the very different way of working needed to make this Bill a reality cannot be over-estimated. Although co-design and co-production are beginning to be used in some parts of the public sector, especially in areas where a “whole place” approach is taken, the prevailing mindset in many areas is still one in which citizens and service users are passive recipients of services.  In order to move towards the kind of engagement the Bill describes will require significant work in terms of skilling public sector staff to work with people and communities in a way which recognises assets to be built on, rather than problems to be solved. Similarly, there is a major cultural shift required to move away from the view of public services as delivery agents to passive populations, to a greater focus on localities in which everyone does their bit. 

Yours sincerely

Dr Sara Hayes

On behalf of the Executive Directors of Public Health for the Health Boards of Wales