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Welsh Government Green Paper – A consultation to collect views
about whether a Public Health Bill is needed in Wales
Response from the Older People’s Commissioner for Wales
The Older People’s Commissioner for Wales (the Commissioner)
strongly endorses the proposal to establish a public health bill. Welsh
Government has a significant opportunity under its legislative powers to
develop unified approaches and duties which can and should lead to
significant improvements in the lives of older people within Wales. This
is already taking place in respect of social care, housing and mental
health and it is timely to extend this to public health.
However, the Commissioner strongly suggests that the focus of this bill
be widened to the broader concept of wellbeing and that this be used as
the overriding concept that is used to drive the debate and action in
years to come in relation to public health. A more detailed rationale for
this is explained later in the response. It is important that any new
legislation focuses not on the traditional conceptualisation of public
health but on an overriding concept of health and wellbeing of the people
of Wales. There is a need for strong and engaged debate on the
concept and role of health and wellbeing within Wales. This bigger
debate needs to incorporate discussions on how to empower older
people to establish and maintain wellbeing. An agreed understanding of
what public health and wellbeing means in the 21st century and how it
can be measured needs to be developed. These discussions need to
result in the development and agreement of a high level, clear and
focused vision on the health and wellbeing of the public in Wales. This
should be a precursor to any Bill being drafted and consulted on. The
Commissioner believes that future legislation on public health could give
definitive meaning to wellbeing that is then used as a benchmark against
which other work can be measured.
As part of these discussions, agreement needs to be reached on a
consistent definition of wellbeing. The term has been increasingly used
within Welsh policy making, including those policies affecting older
people, but there is no common definition or understanding across policy
documents. The definition of wellbeing in this Green Paper is different to
that used in other government documents e.g. the Social Services and
Wellbeing Bill, the Housing Bill, but what is generally agreed is that the
quality of life of older people, and hence their wellbeing, is impacted
upon by a wide range of factors including housing, health and social
care, transport and welfare, etc.
The Commissioner has already undertaken work around wellbeing and
is committed to ensuring that the concept of wellbeing is one which in
the future is at the heart of public service delivery. In our shortly to be
published four year Framework for Action we have identified four key
themes that older people have told us are central to delivering a life that
has value, meaning and purpose – and thus creating a sense of
I feel listened to and respected
I can do the things that matter to me
I get the help I need, when I need it, in the way I want it
I live in a place that suits me and my life
The diagram below illustrates these four themes and their interaction:
These four themes, developed following extensive engagement and
consultation with older people across Wales, represent the major
challenges for all of us in public service. The key test for Welsh
Government should be the extent to which any legislation, duties and
supporting action plans are contributing positively to these four
The importance of maintaining and maximizing health and wellbeing in
older age to maintain independence and quality of life cannot be
overstated. Wellbeing needs to be the driver for policy and practice
which is centred on the needs and wishes of older people.
Once a clear vision of the concept and role of public health is developed,
and a robust definition of wellbeing created, they need to be promoted
widely to raise professional and public awareness and understanding of
Any legislation should be a vehicle for transformational change, which
aligns all the systems of public services in Wales around the delivery of
wellbeing. Legislation establishes a framework under which action can
take place, duties be created and all the different systems can be drawn
together with a focus on wellbeing. The Commissioner believes it will be
useful to have the one Bill which can integrate all the relevant legislation.
However, it is important not to overestimate the role of a Bill – it can be a
framework but it doesn’t empower people and duties will need to be
created to ensure system change is achieved. There is a need to
ensure effective monitoring of impact and outcomes. The Commissioner
recommends that there should be a focus on high impact, low cost areas
such as those four identified in her Framework for Action.
Any work going forward will need a strong focus on the following key
 Prevention and Early Intervention
The Green Paper acknowledges that the whole agenda around public
health needs to shift from dealing with ill health to a stronger focus on
improving everyone’s health and wellbeing and preventing ill health.
There is a need for the rebalancing of services towards prevention and
earlier intervention whilst maintaining protection of those who need it.
The Commissioner wants to make clear that her understanding of
preventative services includes a wide range of social support and
assistance to people to retain their independence and quality of life –
and not a narrow focus on illness prevention services (such as
addressing issues around smoking, alcohol intake and diet). Any work
on prevention necessarily has to look at more than just health factors.
Health and social care services need to be more proactive, and focused
on recovery, re-ablement and social inclusion. One way to ensure that
this shift occurs is to introduce a statutory duty on local authorities and
health boards to focus on prevention and early intervention. The
Commissioner is therefore pleased to see that Part 2 of the Social
Services and Wellbeing Bill puts a requirement on local authorities for
“the provision of preventative services by local authorities”. However
this needs expanding to include Health Boards. This will need to include
ensuring full engagement with and procurement/funding of third sector
services and initiatives.
The scope of the Ageing Well in Wales programme, hosted by the Older
People’s Commissioner for Wales, particularly resonates with the overall
public health agenda:
- Support and champion positive changes to attitudes of an ageing
society and give more choice and control to an individual on how they
can age well
- demonstrate and support councils and partners to adapt their policies
to support an ageing population
- contribute to preventative action to reduce the pressure on health and
social care and reduce inequalities across different parts of Wales
There has been some progress with public health issues but progress
has been far too slow in some areas. Despite a wide range of policies
and targeted actions and campaigns, more needs to be done to prevent
ill health and tackle health inequalities which are still significant.
Public health activities are often focussed on individuals and
encouraging them to make changes to their lifestyles and though these
are important and can be effective, public health is much broader than
this, encompassing a range of societal aspects. The Commissioner is
pleased to see that the Green Paper acknowledges the importance of
positive mental wellbeing as well as physical health. This focus on
emotional and mental wellbeing needs to incorporate the issues of social
isolation and loneliness. These can be closely associated with
depression and can also increase the risk of reduced mobility and even
death amongst older people.
In order to improve the health and wellbeing of the population of Wales,
there is a need for greater health literacy amongst the general public.
Health literacy, as a social determinant of health, offers a powerful
opportunity to reduce inequities in health. When people have the
knowledge and skills to seek out, comprehend, evaluate, and use health
information and concepts they can make informed choices, reduce
health risks, and increase their quality of life.
Though the paper acknowledges there is a rising older population and
that this will mean there will likely be an increase in age related disability
– such as sensory and mobility difficulties and dementia - the approach
does not include enough on older people. For example, the section on
non-communicable diseases regarding healthy lifestyles focuses on
younger people but lifestyle issues are just as relevant to older people.
The Royal College of Psychiatrists recently highlighted that ‘substance
misuse in older people is now a growing public health problem, with
effects on health and social care services, and there is now a pressing
need to address this’ (First Report of the Older Persons’ Substance Misuse Working
Group of the Royal College of Psychiatrists College Report CR165, June 2011)
A holistic approach is needed to public health, encompassing all aspects
of society that impact on people’s health and wellbeing. The Green
Paper acknowledges the social and economic determinants of health
such as income, environment and access to high quality care. With
such a wide range of influences on people’s health and wellbeing, a
cross cutting integrated approach is needed to ensure that all aspects
are considered and addressed. This will require effective partnership
working across all sectors, including health, local authorities and the
third sector. Indeed, Marmot’s review into health inequalities, Fair
Society, Healthy Lives: A Strategic Review of Health Inequalities in
England Post-2010 (Feb 2010) argues that the approach to addressing
health inequalities is to create the conditions for people to take control of
their own lives. The review identifies that action is required across the
social determinants of health and is beyond the reach of the NHS alone.
There needs to be a renewed emphasis on the role of local government
along with national government and the third sector and the
Commissioner firmly believes in the need for an integrated approach.
 Impact
The Commissioner believes there is a need to identify 4-5 key impact
areas to change. Clear, measurable outcomes need to be defined with
robust monitoring and reporting mechanisms established so that
progress can be measured. The Commissioner is working with the
Strategy for Older people team on how wellbeing can be measured and
we would be happy to share this work with you. There is an opportunity
to ensure that current work relating to the national outcomes framework,
which the Commissioner is a part of, is also used to inform further work
in this area.
Missed opportunity
As the Green Paper states, as well as legislation, a number of key
developments have helped to progress the public health system in
Wales. However, whilst some of these have been effective, there is
insufficient emphasis on the need for more joint working across all
sectors. In light of the cross cutting nature of the influences on public
health this needs to be addressed. In particular, there is need for more
partnership working between health boards and local authorities.
There is an important opportunity here to promote awareness and
understanding about public health, what it means and to achieve
measurable outcomes in improving the health and wellbeing of the
public in Wales Whilst the Green Paper highlights some of the key
issues around public health it fails to address and embrace the full range
of approaches and actions needed.