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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 Overview 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. Wellbeing As part of these discussions, agreement needs to be reached on a consistent definition of wellbeing. The term has been increasingly used 1 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 wellbeing: 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: 2 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 outcomes. 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 them. Legislation 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. 3 Any work going forward will need a strong focus on the following key aspects: 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 4 - 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) 5 Integration 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 6 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. 7