National Assembly for Wales / Cynulliad Cenedlaethol Cymru
Health and Social Care Committee/ Y Pwyllgor Iechyd a Gofal Cymdeithasol

Public Health (Wales) Bill/ Bil Iechyd y Cyhoedd (Cymru)

Evidence from The Welsh NHS Confederation – PHB 05 / Tystiolaeth gan Conffederasiwn GIG Cymru – PHB 05

The Welsh NHS Confederation response to the Health and Social Care Committee inquiry into the general principles of the Public Health (Wales) Bill.

Contact:

Nesta Lloyd – Jones, Policy and Public Affairs Officer, the Welsh NHS Confederation.

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Date created:

30 June 2015.

Introduction

1. The Welsh NHS Confederation, on behalf of its members, wholeheartedly welcomes the opportunity to respond to the inquiry into the general principles of the Public Health (Wales) Bill.

2. By representing the seven Health Boards and three NHS Trusts in Wales, the Welsh NHS Confederation brings together the full range of organisations that make up the modern NHS in Wales. Our aim is to reflect the different perspectives as well as the common views of the organisations we represent.

3. The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work. Member’s involvement underpins all our various activities and we are pleased to have all Local Health Boards and NHS Trusts in Wales as our members.

4. The Welsh NHS Confederation and its members are committed to working with the Welsh Government and its partners to ensure there is a strong NHS which delivers high quality services to the people of Wales.

Summary

5. Due to the short time frames for responding to the Public Health (Wales) Bill we are not providing detailed answers to all the questions posed at this stage. We will be providing a more detailed response by the closing date, September 4th, but thought it would be beneficial for the Committee to receive comments before the oral evidence session with the Directors of Public Health from Local Health Boards and Public Health Wales NHS Trust on July 9^th. The Welsh NHS Confederation also endorses the written submission that has been provided to the Committee by Public Health Wales NHS Trust and from the Executive Directors of Public Health of the seven Welsh Health Boards.

6. As with our response to earlier consultations relating to this Bill,[i] the Welsh NHS Confederation believes that the Public Health (Wales) Bill provides a golden opportunity to improve the health of the population. The NHS in Wales supports the Bill and is committed to the protection and improvement of the health of the people of Wales and the reduction of health inequalities. All health systems across the UK should work to reduce premature mortality from preventable disease, but this is particularly the case in Wales, which has historically suffered from high levels of chronic ill health.

7. While the Welsh NHS Confederation wholeheartedly supports the Bill, we are disappointed that it does not include a clear and simple preamble which sets out the goals and principles of the law. It is vital that there is a clear vision of what the Bill intends to achieve and the outcomes on which its success will be measured. Health concerns need to be owned across Government departments and by all sectors across Wales. The Well-being of Future Generations (Wales) Act will go some way in ensuring that public bodies work collaboratively to achieve a “healthier Wales”, it is also essential that the Public Health (Wales) Bill places duties on Welsh Ministers and public sector bodies to consider health in all policies and developments which may impact on the health and well-being of the people of Wales.

Part 2: Tobacco and Nicotine Products

Do you agree that the use of e-cigarettes should be banned in enclosed public and work places in Wales, as is currently the case for smoking tobacco?

8. The Welsh NHS Confederation agrees that the use of e-cigarettes should be banned in enclosed public and work places in Wales. While we acknowledge there is limited evidence in relation to the impact of banning e-cigarettes on smoking prevalence, we also acknowledge that legislating against their use in enclosed public places would provide a clear and consistent approach across Wales. This has the potential to positively impact on the enforcement of current smoke-free legislation and will ‘de-normalise’ smoking.

9. While the current research in relation to the use of e-cigarettes is limited, due to their perceived safety, glamorised use and general appeal, the risk remains that e-cigarette use can act as a potential gateway to tobacco products and could ‘normalise’ smoking behaviour and nicotine use. This is particularly relevant to young people in Wales. A number of our members believe that the use of e-cigarettes in enclosed public places risks ‘normalising’ smoking and sends out mixed messages about the impact that nicotine has on people’s health.

10. A number of strategies have been adopted or are being considered to achieve this ‘de-normalisation’ including; prohibition of tobacco advertising, promotion or sponsorship; a ban on smoking in enclosed public spaces, tobacco display ban regulation and standardised packaging. The widespread use of e-cigarettes in public places and their uncontrolled marketing and promotion is likely to undermine the attempts to ‘de-normalise’ smoking behaviour. E-cigarette companies are adopting many of the advertising, promotion and sponsorship approaches of the tobacco industry. This is resulting in advertising of nicotine vaping products, which in some cases closely resemble cigarettes. Evidence from the tobacco field has demonstrated that children and young people are receptive to these messages.

11. The use of e-cigarettes in enclosed public places has the potential to undermine some of the important health gains that have been achieved through the smoking ban in public places. It is very difficult for individuals to differentiate between those smoking tobacco and those using e-cigarettes, therefore making enforcement difficult. Many e-cigarettes look similar to regular cigarettes, making people wary of challenging smokers where bans exist. The use of e-cigarettes in enclosed public places sends mixed messages to the public about smoking acceptance. This has the potential to cause public confusion and undermine the enforcement of smoke-free legislation. The ban on smoking in enclosed public places has been successfully applied in Wales and there is no evidence to suggest that similar legislation relating to the use of e-cigarettes would not have similar compliance. Legislation on the use of these products would provide much needed clarity to ensure a consistent message across Wales.

What are your views on extending restrictions on smoking and e-cigarettes to some non-enclosed spaces (examples might include hospital grounds and children’s playgrounds)?

12. We would support extending the restrictions on smoking and e-cigarettes to some non-enclosed spaces. While there is evidence of voluntary bans being effective in some areas, at present, without legal backing, voluntary behaviours are difficult to enforce. Legislation would send a clear message around smoking being prohibited in these areas and make consistent enforcement much easier. This is particularly relevant in hospital grounds where vulnerable patients are exposed to second-hand smoke from those who refuse to heed the local policies. Ironically many people require NHS services directly because of smoking induced diseases such as cancers of lung, head and neck and gastrointestinal tract, heart diseases, stroke and vascular (circulatory) diseases. Many of these diseases cluster in areas of high deprivation and high smoking prevalence. ‘De- normalising’ smoking is essential if this burden on NHS resource is to be tackled.

Do you believe the provisions in the Bill will achieve a balance between the potential benefits to smokers wishing to quit with any potential disbenefits related to the use of e-cigarettes?

Do you have any views on whether the use of e-cigarettes renormalises smoking behaviours in smoke-free areas, and whether, given their appearance in replicating cigarettes, inadvertently promote smoking?

13. It is difficult to fully answer this question based upon the existing body of evidence. However, as previously highlighted, we believe that the use of e-cigarettes, which can mimic the act of smoking, can help ‘normalise’ tobacco smoking. Their use has the potential to undermine smoking prevention and cessation activity and the important gains that have been achieved in this area to date because e-cigarettes do include nicotine, with some delivering a higher dose of nicotine than cigarettes. Through the Bill there will be a clear and consistent message that smoking (whether of conventional cigarettes or e-cigarettes) is harmful.

14. If we wish to reduce the chances of e-cigarettes becoming a gateway for non-smokers into nicotine addiction or the use of conventional tobacco products, our efforts need first to concentrate upon restricting the marketing and promotion of these devices as many young people do not recognise how susceptible they actually are to the advertising that continually surrounds them. Consideration should be given to potentially banning the use of e-cigarettes that resemble conventional tobacco products in order to eliminate, or at least minimise, confusion over the nature of the product. Hospital smoke free wardens find it very difficult to distinguish between normal cigarettes and some e-cigarettes that mimic appearance of traditional cigarettes. It would be impossible to allow some e-cigarettes and not others.

Do you have any views on whether e-cigarettes are particularly appealing to young people and could lead to a greater uptake of their use among this age group, and which may ultimately lead to smoking tobacco products?

15. We believe that e-cigarettes can act as a gateway to conventional tobacco by appealing to young people and giving the impression that they are a safe alternative, even though they still include addictive and high levels of nicotine. The presentation of e-cigarettes as a safe way to smoke may provide a route to nicotine addiction for children and young people. This is not something to be encouraged and is something that seems to be overlooked in much of the debate and discussion about e-cigarettes. While they may be preferable to smoking tobacco, their use is not something to be encouraged, regardless of whether this leads to use of other nicotine products or not. In addition, it is possible that once established nicotine addiction through e-cigarettes it could lead to tobacco use, although it will be some time before reliable evidence is available that either supports or refutes these concerns.

16. There is little research evidence available on the use of e-cigarettes among young people in the UK, given that the product is still relatively new to the market and the rapid growth in their use has only been within the last three to four years. However the largest international dataset on use of e-cigarettes by young people comes from the USA National Youth Tobacco Survey (NYTS) which evidences a statistically significant increase of e-cigarettes use by students from 2011–2014. This is a survey[ii] of a representative sample of 22,000 middle school (11 – 14 years) and high school children (14 – 18 years) across all 50 US States. The survey showed that e-cigarettes was the product most commonly used by high school students (13.4%) and middle school students (3.9%), with cigarettes third most common for high school students (9.2%) and middle school students (2.5%). The biggest concern about the survey is that the current e-cigarette use among high school students increased from 4.5% (660,000 students) in 2013 to 13.4% (2 million students) in 2014. Among middle school students, current e-cigarette use more than tripled from 1.1% (120,000 students) in 2013 to 3.9% (450,000 students) in 2014. The conclusions from the survey around the implications for public health practice was that due to the rise in the number of students using e-cigarettes it is critical that comprehensive tobacco control and prevention strategies for youths should address all tobacco products and not just cigarettes. Also worrying from the earlier 2012 USA National Youth Tobacco Survey was that while the data suggests that e-cigarette use is largely among tobacco smokers, 20.3% of 11-14 year olds and 7.2% of 14 – 18 year olds were previously non-smokers.

17. We are also concerned about the extent and nature of tobacco industry involvement in the development of the e-cigarette market, and the role of commercial interests in recruiting new and potentially young customers.

Do you have any views on whether restricting the use of e-cigarettes in current smoke-free areas will aid managers of premises to enforce the current non-smoking regime?

18. In relation to the use of e-cigarettes on hospital grounds, legislation would provide a clear message that smoking is not allowed and would aid managers of premises to enforce the current non-smoking regime. This would help strengthen the existing role that NHS staff members currently play in enforcing the voluntary ban on hospital grounds through providing staff with legal backing. A number of our members have voluntary bans across hospital grounds but it is difficult to enforce and it requires a high level of multi-disciplinary support throughout the NHS in Wales. With legal policies in place much of our members’ local implementation of the voluntary ban would be considerably easier.

19. While we support extending restrictions to some non-enclosed spaces, it is vital that those enforcing the Bill are resourced properly because it will require increased support.

Do you agree with the proposal to establish a national register of retailers of tobacco and nicotine products?

Do you believe the establishment of a register will help protect under 18s from accessing tobacco and nicotine products?

20. We agree with the proposal of establishing a national register of retailers of tobacco and nicotine products. Such a register could strengthen the tobacco control agenda in Wales and the proposal is in line with the Tobacco Control Action Plan for Wales. The role of the register in preventing access to tobacco among children is also recognised.

21. We believe that the proposal to establish a register will help protect under 18s from accessing tobacco and nicotine products. A recent survey in England showed that nearly half of young smokers (44%) reported being able to purchase tobacco from retail premises despite the ban on the sale of tobacco products to those under the age of 18.[iii] The register would be an important step towards reducing the number of young people in Wales who become smokers because they will only be able to access tobacco or nicotine produces from registered retailers. Creating a tobacco retail register will also help colleagues in Trading Standards to tackle the problem of under-age sales.

22. The additional information which could be gathered by a registration scheme will support enforcement of under-age sales and assist in enforcement of the display ban by making it easier to identify locations where tobacco is not permitted to be sold. However, while supportive, we have concerns about the resourcing of this initiative centrally and in Local Authorities. Unless the proposal is properly funded, there may be unintended consequences on other critical public health enforcement activity.

Do you believe the proposals relating to tobacco and nicotine products contained in the Bill will contribute to improving public health in Wales?

23. We do believe that the proposals relating to tobacco and nicotine products contained in the Bill will contribute to improving public health in Wales.

24. Additional proposals that our members have put forward around tobacco and nicotine products include:

· E-cigarettes, like tobacco products, should be subject to plain packaging;

· Shops / cafes should be prevented from opening for the sole purpose of selling e-cigarettes and allowing their use within the premises;

· Primary care contractors, such as community pharmacies, should be prevented from selling e-cigarettes;

· There is a need to establish new definitions of smoking status which take account of the widespread use of e-cigarettes and enable population health surveys such as the Welsh Health Survey and patient information systems to accurately distinguish between non-smokers and ex-smokers who are no longer using nicotine products from those who are adopting longer term harm minimisation approaches;

· Ensuring that, where relevant and appropriate, e-cigarettes are subject to the same regulations regarding advertising and marketing as conventional cigarettes (including minimising the attractiveness of dangerous products to children and young people); and

· Adopting a clear position regarding the future research needed to establish the impact of e-cigarettes at population and individual level.

Part 3: Special Procedures

25. We welcome and the introduction of a compulsory national licensing system for practitioners of specified ‘special procedures’ in Wales and that the premises from which the practitioners operate these procedures must be approved. Incompetent practices and procedures can lead to a burden on the NHS which has to pick up short and long term sequelae, as evidenced by the recent serious skin infection cluster necessitating a blood-borne virus look-back exercise in Aneurin Bevan University Health Board. One premise alone created a burden of work for the Health Board that required considerable financial and human resource to address.

26. Such a register would be beneficial in recognising legitimate practitioners and businesses and help to regulate these procedures in Wales. A national licensing system for practitioners and the mandatory licensing conditions which they have to comply with will ensure the provision of consistent standards in respect of infection control, cleanliness and hygiene for all practitioners and businesses operating any of the listed treatments. It will be essential that competency to perform certain procedures is tested. Almost all GPs and Dentists would not attempt any procedure on the human tongue without full resuscitation facilities available due to the risk of haemorrhage and airway obstruction. Dentists are seeing tongue piercings that have gone wrong on a regular basis.

27. We support the definition of the ‘special procedures’ included within the Bill (acupuncture, body piercing, electrolysis and tattooing), however this Bill also presents an opportunity to regulate the administration of the following procedures: body modification (to include stretching, scarification, sub-dermal implantation/3D implants, branding and tongue splitting), injection of any liquid into the body, for example botox or dermal fillers, dental jewellery, chemical peels, and laser treatments such as used for tattoo removal or in hair removal. It is important that, due to the rapidly changing environment, that the legislation is flexible enough to include other procedures in the future.

28. We would also like this Bill to go further by requiring those registering to undertake such procedures to meet national standardised training where criteria of competency will have been met, including hygiene standards, age requirements and ensuring that they have no criminal background that would make them unsuitable to undertake ‘special procedures’ (for example Child Protection and CRB checks). We would advise that registration should include mandatory proof of identity of the practitioner. These measures would ensure that they have the knowledge, skills and experience needed to perform these procedures.

Part 4: Intimate Piercing

29. We support the proposals within the Bill that prohibits the intimate piercing of anyone under the age of 16 in Wales. This will aid in protecting the public and ensure a clear and consistent message across Wales. The recent look back exercise in Wales demonstrates that intimate piercing is not uncommon in this age group and we welcome the outlawing of intimate piercing irrespective of parental consent. We would encourage mandatory proof of age for any client undergoing a ‘special procedure’ or intimate piercing. It should be noted with concern that girls as young as 13 had undergone nipple piercing in the recent Gwent look-back exercise.

30. We would recommend that the list of intimate body parts includes tongue piercing because of the risks associated, including infection, chipped teeth, blood poisoning, tongue swelling and blood loss which may cause a risk to someone’s airways. Through the Bill children and young people will be protected from the potential health harms which can be caused by intimate piercing. Competency checks will also be required before nipple, genital and tongue piercing, and before body modification such as ear cartilage removal, tongue splitting and branding. Currently there are no checks on the ability of the practitioner to conduct these forms of minor surgery which are much more invasive than most minor surgery performed in primary care for which General Practitioners need additional qualifications.

Part 5: Pharmaceutical Services

Do you believe the proposals in the Bill will achieve the aim of improving the planning and delivery of pharmaceutical services in Wales?

31. The proposals in the Bill will achieve the aim of improving the planning and delivery of pharmaceutical services in Wales. The Welsh NHS Confederation is pleased to note that the Bill recognises the important role that pharmacists can play in improving the health and well-being of the public. Requiring Health Boards to prepare and publish an assessment of the need for pharmaceutical services in its area is a step towards integrating pharmaceutical care and pharmaceutical services into the planning processes of the Health Board. Community pharmacies should play a stronger role in promoting and protecting the health of individuals, families and local communities as part of a network of local health care services.

32. The pharmaceutical needs assessments need to be tightly integrated into the Health Board Integrated Medium Term Plan (IMTP) cycle, driving planning and delivery of services. The pharmaceutical needs assessment will likely consist of information which is already in the local health and well-being needs assessment (and therefore not need to be duplicated), along with information on services currently being provided through pharmacies and their locations. This latter new information might be best assessed in conjunction with the location and accessibility of other NHS services, for example primary care and hospital services.

33. Pharmaceutical needs assessments should examine the demographics of their local population, across the area and in different localities, and their needs. Pharmaceutical needs assessments should describe the pharmacies and the services they already provide. These will include dispensing, providing advice on health, medicines reviews and local public health services, such as stop smoking, sexual health and support for drug users. They should describe accessibility to these services, including by public transport. Pharmaceutical needs assessments should look at other services, such as dispensing by GP surgeries, and services available in neighbouring areas that might affect the need for services in its own area. They should examine whether there are gaps that could be met by providing more pharmacy services, or through opening more pharmacies. Over provision of pharmacies in particular areas should be considered and the pharmaceutical needs assessments should also take account of likely future needs.

Do you believe the proposals relating to pharmaceutical services in the Bill will contribute to improving public health in Wales?

34. The Welsh NHS Confederation agrees that there is considerable public health benefit to be gained by ensuring that Local Health Boards have a stronger role in planning pharmaceutical services in their areas. Community services play an important role in delivering public health services, including community pharmacies. The Bill provides an opportunity to ensure that the public are aware of the services that they can receive and access locally to remain in good health.

35. The Bill recognises the important role that community services can play in delivering public health services. The NHS has historically undervalued the role that community pharmacy can play in improving and maintaining the public’s health. However, there is increasing recognition that community pharmacists can make a significant contribution to improving the public’s health. Community pharmacy and the NHS share a common purpose in a number of areas:

· Public health, pharmacists and their teams already have a track record in delivering public health services, such as promoting and supporting good sexual health, reducing substance misuse within communities, stop smoking services to help people quit and weight management services to promote healthier eating and lifestyles;

· Support for independent living, by helping people to understand the correct use and management of medicines as well as provide healthy lifestyle advice and support for self-care, pharmacists and their teams can help contribute to better health, reduce admissions to hospital and help people remain independent for longer;

· Making every contact count, by using their position at the heart of communities pharmacies can use every interaction as an opportunity for a health-promoting intervention, as signposters, facilitators and providers of a wide range of public health and other health and well-being services.

36. The NHS Confederation’s discussion paper ‘Health on the high street: rethinking the role of community pharmacy’[iv] highlights that evidence is emerging around the potential role community pharmacy can play in improving and maintaining the nation’s health. The paper finds that, as trusted and professional partners in supporting individual, family and community health, sitting at the heart of our communities, effective community pharmacy services have a significant and increased role to play in ensuring we have a sustainable healthcare system and that the NHS is able to survive and thrive over the coming decades. However, this will require providers, patients and the public to be more aware of community pharmacy’s role alongside other primary and community care service, as highlighted within the Health and Social Care Committee’s inquiry into community pharmacies in August 2011. The Committee’s report clearly demonstrated the contribution that community pharmacy can have on the health service but better communication mechanisms are needed to inform the general public about the services available at any individual community pharmacy.

Part 6: Provision of Toilets

37. The Welsh NHS Confederation supports the requirement that each Local Authority will have to prepare and publish a local toilets strategy, which assesses the need for public toilets in its area, and sets out steps that the authority proposes to take to meet that need. The adequate provision of and access to toilets for public use is an important public health issue.

38. Accessible public toilets are a necessity to maintain population health for everyone, but some groups have specific needs. These include disabled people, parents with babies and young children, pregnant women, older people and those with specific conditions including incontinence, inflammatory bowel disease, irritable bowel syndrome, multiple sclerosis and people who have been prescribed diuretics. If toilet provision is inadequate, people can become afraid or reluctant to go away from the home for periods of time, leading to poor mobility, isolation and depression.[v]

39. While the preparation of a strategy that considers the need for and plans for the future provision of toilets for public use would provide clarity at the local level (for elected members, officers and the public) the real issue of making resources available to address this remains. The duty on Local Authorities within the Bill is that they “may provide toilets in its area for use by the public” and the writing of a strategy alone will not automatically improve provision because of the significant financial pressures already experienced by Local Authorities.

40. The statutory duty to write a strategy will have little impact on actual provision, unless resources can be identified to put such a strategy in place. This presents challenges in Local Authorities’ ability to safeguard existing provision and to promote new facilities. We believe that any additional duties placed on Local Authorities should be adequately funded, as some previous closures have been due to heavy maintenance and upgrading costs. The preparation of a local strategy may not result in improved provision and accessibility without adequate resources provided to Local Authorities to implement such a strategy.

41. In addition to the duties the Bill places on Local Authorities, consideration and awareness needs to be increased around other schemes. The public access Community Toilet Scheme introduced in 2009 is reportedly underused with large variation between Local Authorities and some people are not comfortable with using this type of facility. This is a scheme through which people can use the toilet facilities in participating local businesses when they are open, without having to make a purchase. However communication of location and access to potential users can be inadequate and access is necessarily limited to business opening hours.

42. The problem of lack of street signage can also be an issue to accessing public toilets. Signage should be standardised, showing opening times and facilities available. Examples of alternative sources of information which exist elsewhere include Australia’s National Toilet Map, the UK disabled drivers’ mapping portal and Westminster City Council’s SatLAV, which allows visitors to text for their nearest toilet and opening times.

Finance questions

43. As highlighted above, some aspects of the Bill will need resourcing and Local Authorities are likely to incur costs due to the increased duties placed on them as a result of the Bill. It is important that any requirement on local government is proportionate to the issue. We recognise that, as with NHS services, severe strain has been placed on local government services during the economic downturn and that difficult choices have had to be made around the prioritisation of services provided in local communities, many of which are direct determinants of health. With any new duty there is an opportunity cost around what can be provided with limited resource.

Other comments

Food Standards

44. The Welsh NHS Confederation is disappointed that regulation of food standards in settings such as pre-school and care homes are not included in the Public Health (Wales) Bill. Food standards can make an important impact on public health. Good nutrition in very young children is essential for future growth development and health, while poor nutrition in care homes is likely to undermine their health and well-being and increase the chances of the need for health services intervention.

45. We strongly are persuaded that this aspect could be strengthened so that there is no missed opportunity to place mandatory food standards on all food or drink supplied by or procured for settings directly controlled, commissioned or inspected by public sector organisations.

46. Maintaining food standards, particularly in health settings such as hospitals which seek to keep people well, can inform and influence the public’s perception of what foods are considered acceptable and healthy. The public sector caters for some of the poorest and most vulnerable people in society. Catering Standards for Food and Fluid Provision for Hospital Inpatients, and the All Wales Hospital Menu Framework standards ensure patients receive adequate nutrition to assist with their recovery whilst in hospital, but there is much work needed to make sure that healthy and balanced meals and food are offered to all those accessing the restaurants (including staff, patients and visitors). Mandated criteria for the provision of only healthier retail items in hospital restaurants and outlets would help hospitals in Wales to fulfil their responsibility for improving the health of the population they serve.

47. We would welcome the extension of the Welsh Government’s Health Promoting Hospital Vending Directive into other public sector settings, such as Local Authority premises including leisure centres and community centres, and feel that there is also a need to introduce food standards into the wider private sector.

A clear vision for the role public health plays in Wales

48. While the Welsh NHS Confederation supports the Bill, it is disappointing that the vision and the outcomes that the Bill is trying to achieve are not included. As it stands the Bill deals with areas that could predominantly be dealt with through secondary legislation and it does not include a clear vision which sets out the goals and principles of the law. We believe it is important that the Bill includes information to explain clearly to the public that public health is everybody’s business, and not solely confined to the NHS and the public sector.

49. With the Public Health (Wales) Bill there is a once in a generation opportunity to place public health at the centre of our public policy and practice in Wales in order to enable people to live healthy, long lives with a public service that is organised to promote self-care, prevent ill-health and keep people healthier for longer. The future success of the NHS relies on us all taking a proactive approach to public health and ensuring that we create the right conditions to enable people in Wales to live active and healthy lifestyles.

50. Through introducing this Bill we have an opportunity to make Wales a nation that takes the health of its citizens very seriously. There is an over-riding case for the Bill to take advantage of this ‘once in a lifetime opportunity’ to raise the profile of public health in society. In addition we have the opportunity to increase awareness and knowledge of public health across all Government departments, and among those who develop and implement policy, to support the population to live long, healthy and independent lives.

To tackle public health issues we need better integration

51. It is vital that when considering public health issues, the Bill ensures that all Government departments and public bodies work in an integrated and holistic way. While the Well-being of Future Generations Act 2015 goes some way to achieving this, it is essential that the Public Health (Wales) Bill places a duty on Welsh Ministers and public sector bodies to consider health in all policies and developments which might impact upon the health and well-being of the people of Wales.

52. The Bill should ensure that the Welsh Government is obliged to consider the impact on the health of the population in developing and appraising policies in all Government areas. In addition to Welsh Ministers, it is essential that the Bill places duties on all public sector bodies to consider health in all policies and developments which might impact on the health and well-being of the people of Wales, for example closing or limiting access to leisure centres, public transport and provision of safe green spaces.

53. As the Welsh NHS Confederation’s ‘From Rhetoric to Reality – NHS Wales in 10 years’ time’[vi] highlighted, engagement with all our public service colleagues is necessary to take us all from an ill health service that puts unnecessary pressure on hospital services, to one that promotes healthy lives. Engagement is necessary with all our public service colleagues, from social care to housing, education and transport. All public bodies in Wales must build on how we might improve our ability to work together and support our partners and colleagues in other sectors.

54. The Public Health (Wales) Bill is a crucial first step in tackling the culture of ill health in Wales recognising that health is much more than health services. Better health is the responsibility of all sectors and while the Welsh Government has already taken steps to infuse health into various sectors through, for example, legislation for children and young people, housing and active travel, the Bill is an opportunity to progress this work further. We believe through having health in all policies it will raise the profile of public health in society, increasing awareness and knowledge of important public health issues across government departments and in all sectors.

People in Wales are empowered to take control of their health

55. Public health plays a key role in ensuring that we reduce demand and empower people to take control of their health. The introduction of this legislation can renew focus on prevention and well-being and contribute to achieving prudent healthcare in NHS Wales. However, to ensure that this is done people need to be educated and empowered to have the knowledge and understanding to remain in good health and receive appropriate interventions.

56. We must continue to drive a mass shift in public thinking. In relation to people in poor health, the NHS needs to communicate with people and ensure that they are aware of the decisions that they are making and how they are impacting on their health. In terms of how services are used, the re-education of the public is vital and we must involve the public fully in deliberating what the NHS will and will not provide in future and we need to look at the ways public bodies co-produce services with the public.

To improve public health it is essential to tackle poverty

57. Under the Public Health (Wales) Bill the Welsh Government should provide greater consideration to the impact poverty has on the health of the population. The importance of tackling poverty to improve people’s health cannot be underestimated. Poverty and deprivation are linked to many of the public health concerns and outcomes in Wales.

58. There are still significant health inequalities, including by age, ethnicity and socio-economic group.[vii] The Welsh NHS Confederation recently published the ‘Socio-economic deprivation and health’[viii]briefing. This highlights the correlation between socio-economic deprivation and people’s health and well-being outcomes, with the gap in life expectancy for people living in the most deprived and the least deprived areas of Wales currently stands at 9.2 years for men and 7.1 years for women for all Wales.[ix] In some Health Boards the discrepancy in healthy life expectancy between the most and least deprived is over 20 years. Through analysing trends across socio-economic groups we highlight how deprivation has an impact on child development, people’s lifestyle choices, healthy life expectancy, including living with an illness or chronic condition, and life expectancy. It is now the time for all public sector organisations, including the health service, to work together to tackle deprivation and inequality. Through the Public Health (Wales) Bill and the Well-being of Future Generations (Wales) Act it is imperative that collaboration across all public bodies improves to achieve a “healthier Wales” and an “equal Wales”. We must deliver a more integrated and preventative approach for our public’s health that has maximum impact to reduce inequalities and keep people healthier for longer.

Conclusion

59. While the debate around this Bill has predominately focused on e-cigarettes it is vital to recognise the key role that public health plays in reducing health inequalities, ensuring positive outcomes for the Welsh population and reducing demand on the NHS. While the demand for NHS services will never go away, the point at which the NHS intervenes has huge implications on both the cost and quality of care provided. By working with public health initiatives, and allowing the public to take more responsibility for their own health, we can reduce the complexity, and therefore the demand, of some of our highest need cases. Services in Wales need to be integrated, person-centred, co-ordinated, community based and focused on people’s well-being. We hope that the Public Health (Wales) Bill goes some considerable way in helping to achieve this.