PHB 03
Bil Iechyd y Cyhoedd (Cymru)
Public Health (Wales) Bill
Ymateb gan: Conffederasiwn GIG Cymru
Response from: Welsh NHS Confederation


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


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



25 November 2016.



1.   The Welsh NHS Confederation, which represents the seven Health Boards and three NHS Trusts in Wales, welcomes the opportunity to respond to the inquiry into the general principles of the Public Health (Wales) Bill.


2.   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.


3.   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, person-centred services to the people of Wales.




4.   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.


5.   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 and well-being needs to be owned across Government departments and by all sectors across Wales. The Well-being of Future Generations (Wales) Act 2015 goes 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.


6.   The Welsh NHS Confederation recently published a briefing for Assembly Members,[ii] attached with this submission, which set out the public health challenges in Wales and the steps needed most urgently over the course of the fifth Assembly to aid the sustainable health and well-being for the people of Wales. The next five years represent a critical period of transformation in health and care services in Wales. The NHS will continue to work across Government and public sector partners to invest time and resources in services that promote health and well-being and shift resources towards community based interventions. To achieve a healthier, happier and fairer Wales, it is also key that the public are empowered and informed to take responsibility for their own health and well-being.



General principles of the Public Health (Wales) Bill


Tobacco and Nicotine Products

Re-state restrictions on smoking in enclosed and substantially enclosed public and work places, and give Welsh Ministers a regulation-making power to extend the restrictions on smoking to additional premises or vehicles.

7.   We would support the restrictions on smoking in enclosed and substantially enclosed public and work places and agree that the Welsh Ministers should have regulation-making powers to extend the restrictions on smoking to additional premises or vehicles.


8.   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. Many people require NHS services directly because of smoking-induced diseases such as cancer, 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.


Place restrictions on smoking in school grounds, hospital grounds and public playgrounds

9.   We would support the restrictions on smoking in school grounds, hospital grounds and public playgrounds. At present all Health Boards have individual Smoke Free Environment policies, which includes the prohibiting of e-cigarette use, and having this in legislation would be useful. Legislation would provide a clear message that smoking is not allowed and would aid managers of premises to enforce the current non-smoking regime.


10.        In addition in relation to placing restrictions on certain premises we would recommend that prison estates are included. Like hospitals, all prisons in Wales, including the soon to open HMP Berwen, are smoke free. Enshrining it in legislation would be a positive step to reinforce the measure. The inclusion of secure hospitals, and whether the current exemption for psychiatric units should remain, should also be considered. Finally we would recommend extending smoke free spaces into outdoor areas frequented by children and the margins of buildings that have smoking restrictions.



Provide for the creation of a national register of retailers of tobacco and nicotine products.

11.        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. We would recommend that the role of the register in preventing access to tobacco among children is also recognised. Having a requirement for tobacco retailers to display information about quit smoking support would also be useful.


12.        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.


13.        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. 



Provide Welsh Ministers with a regulation-making power to add to the offences which contribute to a Restricted Premises Order (RPO) in Wales.

14.        We agree that Welsh Ministers should be provided with a regulation-making power to add to the offences which contribute to a Restricted Premises Order (RPO). We would support the proposal to enable local authority enforcement officers to introduce a RPO. However, as prosecutions for noncompliance with under age sales regulations are infrequent, it seems unlikely in practice that retailers would be identified as having repeated infringement of the regulations. We would suggest that consideration be given to a 12 month order following a single infringement or at least the powers to make an application to a magistrate to grant an RSO or RPO.  We would suggest that repeated infringement should carry a longer term restriction.


Prohibit the handing over of tobacco and/or nicotine products to a person under the age of 18.

15.        We would support the prohibition of handling over of tobacco and/ or nicotine products to a person under the age of 18. The growth of online shopping would suggest the need to revisit all age restricted sales in this way. 



Other comments

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

·         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.


Special Procedures

Provide for the creation of a mandatory licensing scheme for practitioners and businesses carrying out ’special procedures’, namely acupuncture, body piercing, electrolysis and tattooing.

17.        We welcome 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 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. We would recommend that the Committee considers the findings of the recent report published by Aneurin Bevan University Health Board “The Technical Report of a Blood‐Borne Virus Look‐Back Exercise related to a body piercing and tattooing studio in Newport, South Wales”[iv] and the recommendations within the report. The recommendations included:

·         Education of young people about risks of tattooing and piercing including blood borne viruses and bacterial infections should be supported nationally.

·         There is a need for improved regulatory powers for the enforcement of hygiene measures in body piercing/tattooing premises. There are better safeguards in place with regard to buying a sandwich than having potentially harmful procedures such as tongue piercing currently.

·         All premises performing body piercing/tattooing should keep detailed client lists and consent forms with address and contact numbers.

·         Intimate piercing should only be performed over the age of 16 where documented proof of age is demonstrated.

·         The piercing/tattooing of intimate areas can be considered a safeguarding issue, if the client is not of age or is vulnerable in other ways and it is recommended that these procedures are carried out by a same sex practitioner preferably in the presence of a client advocate.

·         All tattooing and body piercing practitioners should have DBS checks completed and undergo safeguarding training.

·         Registration/licensing to perform tattooing/piercing should be on an individual basis of competency based on understanding of infection control, safeguarding legislation, technical aspects and practical skills, similar to other forms of minor surgery e.g. cosmetic. The current situation, whereby anyone with no training can open for trading with no quality assurance, is unacceptable particularly with ever invasive procedures e.g. tongue piercing, body modification.

·         Substantiated complaints against an individual should revoke licence until a period of retraining and reaccreditation fulfilled.

·         Local authorities should have shared databases of licensed practitioners and those whose licence has been revoked.

·         There should be awareness‐raising among GPs and ENT doctors so that if anyone presents with infection following piercing/tattooing they alert the local Health Protection team urgently.


18.        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.


19.        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 certain liquids into the body, for example botox, dermal fillers and dermal rolling/micro needling, 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.


20.        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.


Intimate Piercing

Introduce a prohibition on the intimate piercing of persons under the age of 16 years.

21.        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.


22.        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.



Require Welsh Ministers to make regulations to require public bodies to carry out health impact assessments in specified circumstances

23.        We support the proposal that requires the undertaking and publication of health impact assessments (HIA) by public bodies in specified circumstances and we are pleased that this is included in Part 5 of the Public Health (Wales) Bill 2016. We believe that this inclusion will strengthen the focus on improving population health and well-being and facilitate action-oriented partnership working. This mandatory requirement will support good public health practice across local and national organisations and explicitly reinforce Welsh Government commitment to a ‘Health in all Policies’ approach which is implicit within the Well-being of the Future Generations (Wales) Act 2015.


24.        We have consistently called for HIA to be introduced in Wales. In our response to the previous Public Health (Wales) Bill, and also in our Briefing for the National Assembly election,[v] we called for a ‘Health in All Policies’ approach being adopted across sectors to ensure the impacts on health, well-being and equity are known and harms are minimised and mitigated.


25.        HIA could make Wales an international exemplar in the field of public health. Pre-assessing new policies, plans or programmes in order to avoid any unforeseen negative impacts on the environment or equalities is already well-established within decision-making by public bodies in Wales. However, there is also a strong case to be made that we should be equally seeking to avoid or minimise any negative impacts on the health and well-being of the Welsh population, as well as promoting positive impacts. It also makes sense in light of the accepted recognition that health is, to a large extent, determined by factors outside of healthcare provision. Known as the wider determinants of health, these include social and community factors; access to services; and economic and environmental factors, as highlighted in our recent “Public Health Challenges in Wales” briefing.[vi]


26.        We welcome the development of regulations to inform the implementation of HIAs by public bodies. We request that a broad holistic approach be adopted when considering the circumstances in which a public body carries out a HIA and include the assessment of actions or decisions that are not normally considered to be health related. For example, Public Service Board’s Well-being Plans, major Health Board or local authority service re-configurations, land use plans, policy decisions on classification and location of hot food take-aways, national and local education policies. We also support the requirement that all Welsh Government policies are systematically assessed for their potential positive and negative or unintended consequences on health and well-being; undertaking HIAs on national policies will support delivery at a local level.


27.        A number of governmental strategic levers and drivers currently exist and HIAs are explicitly referred to in Welsh Government guidance in a wide range of areas, including road and rail transport, land use planning and regeneration plans, for example. HIA is already a mandatory requirement within the NHS in Wales in respect of investment in infrastructure and capital build projects. We suggest that provision for statutory HIAs commence where already referred to in order to help build and expand the body of HIA work available.


28.        HIAs should be required in a way that is manageable and proportionate to the size, scale, scope, significance and nature of any policy, plan or proposal. It should make best use of the resources, knowledge, expertise and evidence available.  We recommend that a requirement be included for HIAs to be completed across development stages and that the process be proportionate but still provide helpful and robust information that supports decision making.  We also suggest that any method for undertaking HIA needs to be a core component of any organisation’s approach, adding a health dimension to the current impact assessments that are currently used routinely.


29.        We would like to stress that HIAs should be viewed as a tool to support public bodies to address inequalities and inequities in health and inform actions that strengthen positive impacts and mitigate negative impacts. We believe that it is essential that HIAs are undertaken in consistent and effective ways and that the process be effectively understood and positively followed both upstream at a governmental level and downstream at a local level.


30.        We recommend that consideration needs to be given to capacity and the role of a wide range of organisations to develop systems, and ensure people have the support and skills to undertake HIAs. Public Health Wales NHS Trust, and specifically the Wales Health Impact Assessment Support Unit, has a clear role in supporting capacity development through training and the provision of support such as mentoring practitioners and there needs to be an increased corresponding resource for this.


31.        As the Welsh NHS Confederation’s “From Rhetoric to Reality – NHS Wales in 10 years’ time”[vii] 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.


32.        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.


Pharmaceutical Services

Change the arrangements for determining applications for entry onto the pharmaceutical list of health boards (LHBs), to a system based on the pharmaceutical needs of local communities

33.        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.


34.        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.


35.        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.


36.        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. 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.


37.        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 sign-posters, facilitators and providers of a wide range of public health and other health and well-being services.


38.        The NHS Confederation’s discussion paper ‘Health on the high street: rethinking the role of community pharmacy’[viii] 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.



Provision of Toilets

Require local authorities to prepare a local strategy to plan how they will meet the needs of their communities for accessing toilet facilities for public use

39.        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.


40.        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.[ix]


41.        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 writing of a strategy alone will not automatically improve provision because of the significant financial pressures already experienced by Local Authorities.


42.        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. A requirement to undertake HIAs of changes to service provision and policy decisions would permit the consideration of the adequacy of public toilet provision in an area. 


43.        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.


44.        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.



Food Standards

Enable a ‘food authority’ under the Food Hygiene Rating (Wales) Act 2013 to retain fixed penalty receipts resulting from offences under that Act, for the purpose of enforcing the food hygiene rating scheme.

45.        The Welsh NHS Confederation supports this new offence. Food standards can make an important impact on public health. 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. 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).


46.        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.



Any potential barriers to the implementation of these provisions and whether the Bill takes account of them.

The financial implications of the Bill.

47.        One of the biggest barriers to implementation of these provisions are the financial implications of that some duties will have. 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

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.        By 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.



People in Wales are empowered to take control of their health

51.        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.


52.        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

53.        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.


54.        Last year the Welsh NHS Confederation published the ‘Socio-economic deprivation and health’[x]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.[xi] 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 20015 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.




55.        While the Public Health (Wales) Bill is debated 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.


56.        With the introduction of the Public Health (Wales) Bill, now is the time for us all to act together. Through a systems approach - sharing our collective assets, following the principles of sustainability and prudent healthcare and complying with our unique legislation, the Well-being of Future Generations (Wales) Act 2015, we have the opportunity and responsibility to work collaboratively across sectors and organisations. It is essential to listen to and empower our people, and to appreciate the assets within our communities, allowing them an equal part in all decisions and plans for their life, health and happiness. Assembly Members have a key role to ensure that together we can achieve a healthier, happier and fairer Wales.



[i] The Welsh NHS Confederation response to the ‘Listening to you – Your health matters’ White Paper in June 2014 and the ‘Public Health (Wales) Bill’ in July 2015.

[ii] The Welsh NHS Confederation, November 2016. Public Health Challenges in Wales: A briefing for AMs.

[iii] Health & Social Care Information Centre, 2013. Smoking, drinking and drug use among young people in England in 2012.

[iv] Aneurin Bevan University Health Board, July 2016: The Technical Report of a Blood‐Borne Virus Look‐Back Exercise related to a body piercing and tattooing studio in Newport, South Wales.

[v] The Welsh NHS Confederation, October 2015. The 2016 Challenge: A vision for NHS Wales.

[vi] The Welsh NHS Confederation, November 2016. Public Health Challenges in Wales: A briefing for AMs.

[vii]The Welsh NHS Confederation, January 2014. From Rhetoric to Reality – NHS Wales in 10 years’ time.

[viii] The NHS Confederation, 2013. Health on the high street: rethinking the role of community pharmacy.

[ix] Older Peoples Commissioner for Wales, 2014. The Importance and Impact of Community Services within Wales.

[x] The Welsh NHS Confederation, June 2015. Socio-economic deprivation and health.

[xi] Public Health Wales Observatory, December 2011. Measuring inequalities. Trends in mortality and life expectancy in Wales.