Chief Medical Officer for Wales Annual Report 2012-13 Healthier, Happier, Fairer Source: Visit Wales Acknowledgements I would like to thank colleagues from the Welsh Government for contributing to the development and editing of this report. Special thanks to Helen Jones, Hayley Jones and Benjamin Lewis for managing the production of the report, and also to Chris Brereton, David Hands, Suzanne Moore Osley, Dr Heather Payne, Dr Andrew Riley, Dr Chris Riley, Neil Riley, Cath Roberts, Chris Tudor-Smith and Alun Williams. I would also like to acknowledge the contribution made by colleagues in Public Health Wales in providing material and assisting with reviewing the report.
WG18489 © Crown Copyright 2013 ISBN 978 1 4734 0301 7 Chief Medical Officer for Wales Annual Report 2012-13
Letter to the First Minister
Dear First Minister, I am delighted to publish this, my first Annual Report as Chief Medical Officer for Wales. My role as a doctor at the heart of the Welsh Government gives me an opportunity to assess the health and wellbeing of the people of Wales and see where we might do better.
While Wales has developed excellent initiatives and strong systems, this is a difficult time. The economic downturn is making life hard for many people, and that may take a toll on their health. There are no quick fixes for that and its shadow may be long.
Against that backdrop, this report will not be restricted to an account of events in the last year. Instead it will set out an Source: Welsh Government assessment of where Wales stands with regard to health and wellbeing and what may lie ahead.
In this report I portray health not as something separate but as the foundation for a full and enjoyable life. What makes people healthy is much the same as what makes them happy – having a satisfying role in life with prospects, feeling mentally and physically fit, and living in a decent community and a society where people of all ages and backgrounds have a fair chance in life.
Every country is facing similar problems and we need to share ideas and problems with others and learn together. My own experience suggests that there are ideas elsewhere we can pick up and apply in Wales.
Throughout this report I will discuss what could improve or harm health now and in the future. I will also stress the importance of encouraging the whole of government and society to work together to improve people’s lives, and how we can better engage the public and those who provide services in joining together in a way that can work in everyone’s interest.
This report is focused on evidence and opportunities. After a summary of the current position, chapters assess how we could better protect and promote health and wellbeing for all and support the NHS. The final chapter examines the links between health and the economy, a complex area but one potentially containing untapped benefits. Each chapter includes recommendations, which I will return to in future Annual Reports. I conclude with some suggestions on how we can push faster for real improvements in the health and wellbeing of all of us.
Yours sincerely,
Dr Ruth Hussey OBE, Chief Medical Officer, Wales Chief Medical Officer for Wales Annual Report 2012-13
List of Figures
Figure 1: Percentages of Welsh adults 8 Figure 11: Completed immunisations 23 reporting specific health problems, 2012 (all antigens) by 12 months and 24 months in the UK by country, 2011-12 Figure 2: Relationship between chronic 9 conditions and risk factors Figure 12: Quarterly numbers of MRSA 25 bacteraemias from hospital patients in Figure 3: Health behaviour indicators, 2012 10 Wales, April 2008-March 2013
Figure 4: Healthy life expectancy 11 Figure 13: Quarterly numbers of MSSA 26 as a proportion of life expectancy at birth, bacteraemias from hospital patients in 2000-02 to 2008-10 Wales, April 2008-March 2013
Figure 5: Happiness in the UK, levels of 12 Figure 14: Total antibiotic use (expressed 27 medium or high happiness, 2011-12 as dispensed items/1000 prescribing units/ quarter) in the community across Wales, 2005-12 Figure 6: Gap in years of life expectancy 13 between the most and least deprived Figure 15: Adults’ alcohol consumption 37 quintiles of deprivation in Wales above the daily guidelines, 2008-12
Figure 7: Contribution to life expectancy 14 Figure 16: Physical activity among 39 gap (in months) in men under 75 by adults, 2003-12 underlying cause of death, comparing most and least deprived quintiles of Wales, Figure 17: Fruit and vegetable 39 2001-03 and 2008-10 consumption by adults, 2008-12
Figure 8: The Health Map 15 Figure 18: A whole of society approach 42 to promote healthier, happier and fairer lives Figure 9: Notifications of measles in 21 Wales by week Figure 19: The change in the health system 50 in Wales over the past 40 years Figure 10: Summary of uptake rates for 23 selected immunisations in resident children Figure 20: Number of attendances and 51 reaching their 1st, 2nd, 5th and 16th attendance rate per 1,000 population at major birthday between 01/01/13 and 31/03/13 A&E departments in Wales by age, 2012-13 and resident on 31/12/12 Figure 21: Physical and mental wellbeing 61 by socio-economic classification of household, 2012 Chief Medical Officer for Wales Annual Report 2012-13
Substance misuse 40 Contents Making real progress – the whole 40 of government and the whole of society Chapter 1: Wales in the past year – 6 Health assets and health literacy 43 healthy, happy, fair? Health and wellbeing across public services 44 How healthy are we? 7 Priorities for prevention across Wales 46 Health status 7 Recommendations 47 Health behaviours 9 Life expectancy 11 How happy are people in Wales? 12 Chapter 4: Creating safe and resilient 49 How fair is health in Wales? 13 21st century healthcare services The changing nature of the Welsh 50 Health, happiness and fairness – 15 health system the wellbeing of Wales The impact of population change 51 Recommendations 17 Economic factors 52 How much to spend on healthcare? 52 Chapter 2: Protecting the nation’s health 19 A relentless focus on quality 52 Infection 20 Clinical staffing and leadership 53 Avian influenza A(H7N9) 20 Fair and flexible healthcare 54 Middle East respiratory syndrome 20 A partnership with the public – co-production 54 coronavirus (MERS-CoV) A health service for the 21st century – 55 Measles 21 balanced and innovative Immunisation 22 Looking forward 56 Sexual health 24 Recommendations 57 HIV awareness raising campaign Healthcare associated infections (HCAI) 24 Clostridium difficile (C. diff) 25 Chapter 5: Acting on the relationship 59 Staphylococcus aureus (S. aureus) 25 between health and wealth The economic challenge 59 bacteraemias Long-term structural poverty 59 Infection prevention and control (IPC) 26 and deprivation Antibiotic resistance 27 Impact of the economic downturn 60 Wales wide population screening for early 28 Impact of benefit reform 60 detection What can be done about the challenges? 60 Major environmental hazards 28 Supporting people to get into and 61 Air Quality 29 stay in work Climate change and extreme weather events 30 Using regeneration to create better health 63 Lessons learned 32 and wellbeing Recommendations 33 The role of the health and social care 63 sector in economic development Chapter 3: Achieving health and 35 Developing the life-science sector 63 happiness through prevention Skills development 64 Act earlier, prevent more 35 Other possibilities 65 Lifestyle factors 36 Harnessing the potential 65 Smoking 36 Recommendations 66 Alcohol misuse 36 Low levels of physical activity and 38 poor eating habits Conclusions 68 Chapter 1 Wales in the past year – healthy, happy, fair?
In many ways health in Wales is improving. However, some problems continue and action to support healthy behaviours is essential. Happiness levels vary across Wales and there is a need to understand the causes better. The gap between the health of the most deprived and least deprived communities is not decreasing.
There are many positive aspects to report about However, there are challenges. Obesity continues health and wellbeing in Wales. As this year’s report to increase, with an associated rise in diabetes. shows, the Welsh population is living longer than There are more adults being treated for high blood ever and has more years of healthy life than ten pressure and poor mental health remains a problem. years ago. Too few people do enough physical activity. There is still a large gap between the health of the most and least deprived communities1.
2 Source: Visit Wales Chief Medical Officer for Wales Annual Report 2012-13
The purpose of this chapter is to look at the data and intelligence that contribute to understanding the health and wellbeing of the population of Wales. It is divided into three sections, looking firstly at health status, health behaviour, and life expectancy; then at indicators of the relative happiness of the population; and lastly at fairness and the inequalities that continue to affect the lives of people in Wales. These elements together create a picture of health and wellbeing of the more than three million people in Wales.
Further data related to each chapter can be accessed from the data compendium on the Welsh Government website: www.wales.gov.uk/cmo
Source: Public Health Wales
healthcare interventions are available, should be How healthy are we? rare. In 2011, there were 7,470 deaths to Welsh residents caused by conditions considered avoidable, Health status representing about a quarter of all deaths. Avoidable The health status of the population presents a mixed mortality rates for Wales decreased by 26 per cent picture. There has been a long term reduction in over the period 2001-11, but were consistently higher deaths from heart disease and cancer, and Wales has than for England, the rate in Wales being 196.4 per maintained low levels of infant mortality2. However, 100,000 in 2011 against 173.5 in England5. data in the latest Welsh Health Survey shows as many as 34 per cent of Welsh adults have their daily activities affected by a health problem or disability3.
In 2011, there were 30,426 deaths in Wales. Mortality rates have declined by almost a third since 1990, but are higher in more deprived areas. Rates for men are still higher than for women, but have reduced more quickly. The most common causes of death in 2011 remained circulatory disease and cancer, together accounting for slightly fewer than 60 per cent of all deaths. Respiratory diseases accounted for a further 15 per cent of deaths. For people under the age of 45 years, the leading cause of death was from external factors including suicide and road traffic accidents (see data compendium online)4.
‘Avoidable deaths’, that is those caused by certain conditions for which effective public health and Source: Public Health Wales
7 Chief Medical Officer for Wales Annual Report 2012-13
Figure 1: Percentages of Welsh adults reporting specific health problems*, 2012
Source: Welsh Health Survey, 2012
While fewer people are dying each year, there Two in 100 people will have a severe mental illness, remains concern over the number of people who such as schizophrenia or bipolar illness and ten per have conditions that affect their daily life. In 2012, cent of children and young people have a clinically 20 per cent of adults reported currently being recognised mental disorder, with a greater number treated for high blood pressure, 14 per cent for a experiencing behaviour and conduct disorders8. respiratory illness, 12 per cent for arthritis, 11 per Approximately 50 per cent of people with enduring cent for a mental illness, nine per cent for a heart mental health problems will have symptoms by the condition, and seven per cent for diabetes. In time they are 14 years old and many at a much addition, 34 per cent of adults reported that their younger age9. day-to-day activities were limited because of a health problem or disability, including 16 per cent Dementia poses a serious future threat; in the who were very limited. Since the survey started in UK it is estimated that one in 14 people over 65 2003/04, there has been a slight increase in adults years, and one in six over 80 years, have some reporting being treated for high blood pressure, form of dementia. In 2011, it was estimated that mental illness and diabetes, and a slight decrease for the number of people in Wales with dementia had heart conditions and arthritis6. already risen to approximately 43,00010.
Poor mental health remains a concern across the UK. One in four people will experience mental illness in their lifetime, whereas one in six will experience mental illness at any one time7.
8 Chief Medical Officer for Wales Annual Report 2012-13
Health behaviours The health status of the people of Wales is directly An area where progress needs to be made is in related to healthy behaviours and risk factors. relation to childhood obesity. Having trebled over However, it is important to acknowledge that the past 30 years, it is one of the most serious behaviour is often conditioned by people’s social health challenges of the early 21st century, with circumstances, the opportunities and choices serious health consequences, significant reductions available to them and the stresses and pressures in quality of life and a greater risk of bullying and
Figure 2: Relationship between chronic conditions and behavioural risk factors
Conditions
Behavioural
risk factors Cardiovascular diseases 2 diabetes Type Poor health mental kidney Chronic disease Some cancers Injury Osteoporosis diseases Oral Arthritis Asthma COPD*
Tobacco smoking
Physical inactivity
Harmful alcohol use
Poor nutrition
Sources: AIHW National Advisory committee on Oral Health * Chronic obstructive pulmonary disease Source: Australian Institute of Health and Welfare11 they face. These issues have been addressed in some social isolation13. Half depth in previous Chief Medical Officer for Wales of obese school-age Annual Reports, which have also highlighted the links children are likely to between behaviours and the levels of chronic disease become obese adults and injury across the country. Figure 2 summarises with especially high the links between behaviours and health problems. risk of metabolic syndrome14. Moreover, Successive rounds of the Welsh Health Survey since behaviour is offer the opportunity to assess changes in healthy often passed down behaviours in the light of recommendations made through families, 2,10,46,47 46 by the UK Chief Medical Officers. The latest Welsh successful intervention Health Survey 2012 offers positive news, with a is essential to reduction in people who binge drink and who drink safeguard the health above the recommended guidelines. However, the of future generations. decline in the number of smokers has been slow, and Achieving good health in recent years there has been little change in the through prevention is number of people who are physically active on five discussed in Chapter 3. or more days a week (see Figure 3 over the page). This pattern is also experienced in many other health systems around the world12.
Source: Visit Wales
9 Chief Medical Officer for Wales Annual Report 2012-13
Figure 3: Health behaviour indicators, 2012
Source: Welsh Health Survey, 2012
The Welsh Health Survey has also shown that 81 per cent in England. Wales had a higher people’s assessment of their own health has not percentage of residents with a long term illness changed over recent years15. (23 per cent), than any region of England. The pattern of poorer health in Wales has persisted since By comparison, in the UK 2011 Census, 78 per cent the previous Census in 2001 and the Wales-England of people in Wales reported that their general health gap in those reporting ‘good health’ has widened16. was ‘very good’ or ‘good’, compared with
Table 1: Self-reported general health status of adults in Wales Poor Fair Good Very good Excellent 2003/04 6 15 28 34 16 2008 6 15 29 34 16 2012 6 15 29 35 15 Source: Welsh Health Survey, 2003/4, 2008, 2012
10 Chief Medical Officer for Wales Annual Report 2012-13
Life expectancy
Figure 4: Healthy life expectancy as a proportion of life expectancy at birth, 2000-02 to 2008-10
Source: Office for National Statistics17
The population of Wales continues to grow and live longer. In 2011 there were estimated to be 3.1 million people in Wales, 49 per cent male and 51 per cent female. There were slightly more people (18.5 per cent) aged 65 years and over than children under 16 years (18.1 per cent).
Overall, life expectancy in Wales continues to improve. In 2009-11 life expectancy was 78.0 years for men and 82.2 years for women18. Healthy life expectancy is also lengthening, though the rise is not constant year on year (Figure 4). In 2008-10 the average healthy life expectancy was 63 years for both men and women, meaning that although women live longer than men, their general health is poorer for a longer period of their lives. At present, it is expected that men will spend 81.3 per cent of their lives in good health, compared with 77.2 per cent for women19.
Source: Visit Wales
11 Chief Medical Officer for Wales Annual Report 2012-13
not felt happier. He lists the ‘big seven’ factors How happy are affecting happiness: financial situation, family relationships, work, community and friends, health, people in Wales? personal freedom and personal values21. An important lesson of recent years is the appreciation People’s sense of happiness or wellbeing varies that national prosperity and wellbeing are not just across the country. An Office for National Statistics a matter of economic wealth. Work from the UK (ONS) survey of 165,000 adults between April 2011 Government Foresight Unit recognises the importance and March 2012 found there were big differences in of resilience and mental wellbeing in enabling people how happy people were in different places. People to live lives that are more than just ‘existing’20. in Anglesey were the third happiest in the UK, with Health is closely linked to our enjoyment of life, Blaenau Gwent and Swansea ranking in the four but neither happiness nor health is simple. The least happy areas*22. economist Richard Layard has analysed the paradox * based on proportion of people giving medium to high ratings that while the country has got richer, people have for happiness.
Figure 5: Happiness in the UK, levels of medium or high happiness, 2011-12
Source: Office for National Statistics
12 Chief Medical Officer for Wales Annual Report 2012-13
Differences in happiness and health both appear strongly related to social circumstances. Happiness How fair is levels were related to being in work; only 20 per cent of employed people rating low ‘life satisfaction’ compared health in Wales? with 45 per cent for the unemployed. Perceived good The third component of our understanding of health health also correlated positively with happiness. and wellbeing in 21st century Wales is fairness. Significant inequalities in health continue to exist In addition, adults who were married or in a civil across the country, men in the most deprived areas partnership tended to report higher ratings for having almost eight years lower life expectancy and life satisfaction, with those who were divorced or women about six years lower, compared with the separated reporting the lowest ratings. least deprived areas24. The previous widening of the gap has stabilised and it is a positive sign that Of young people in Wales (aged 11 to 16 years) 83 this difference in life expectancy between rich and per cent reported high life satisfaction (a score of poor has not increased in the past few years. Figure six or more out of ten, where ten indicates the best 6 shows recent trends and Figure 7 over the page possible life satisfaction and zero the worst). Boys draws out some of the causes. were slightly more likely than girls to rate themselves as satisfied with their lives. The more affluent the Inequalities remain a major concern for health family background, the more likely children were to and wellbeing in Wales and it will be important rate themselves as satisfied with their lives23. to monitor this trend over the coming years, particularly in light of economic and welfare changes. To try to understand better the causes of this persistent inequality and how best to tackle it, Cwm Taf and Aneurin Bevan Local Health Boards are looking at implementing learning from evidence- based approaches used in other parts of the UK.
Figure 6: Gap in years of life expectancy between the most and least deprived quintiles of deprivation in Wales
Source: Welsh Government 13 Chief Medical Officer for Wales Annual Report 2012-13
Figure 7: Contribution to life expectancy gap (in months) in men under 75 years by underlying cause of death, comparing most and least deprived quintiles of Wales, 2001-03 and 2008-10
Source: Public Health Wales
When people die prematurely, it has a large impact expectancy between the least and most deprived on the overall life expectancy of a population. areas of Wales. Tackling the higher smoking rates Looking at the major causes of premature death in more deprived areas is an opportunity to further can show the gains in overall life expectancy that reduce this gap. In both genders, the contribution of could be made if such deaths were prevented. For premature death from digestive disease to the life example, as shown in Figure 7, deaths from coronary expectancy gap has increased, which is of concern heart disease in men aged under 75 years account given the links between alcohol and liver cirrhosis. for around a year’s worth of the overall gap in life
14 Source: Welsh Government Chief Medical Officer for Wales Annual Report 2012-13
development in the current Assembly term to Health, happiness strengthen this approach. and fairness – the It must also be accepted that making progress is not simply a matter of chipping away at an easily wellbeing of Wales defined set of problems. Figure 8 is a reminder of the To summarise, despite improvement, health in number and diversity of factors can benefit or harm Wales could be better and more still needs to be health25. The situation is fluid and the challenges done to tackle the inherited problems. Many health will continue to change, as will our ability to deal problems are known to be avoidable. Letting things with them. Table 2 on the next page sets out some go wrong and then trying to rectify them is wasteful current issues and future threats to the health of the and costly. It is also contrary to the principle of population, presenting them in terms of the three sustainable development to which the Welsh elements of sustainable development often used in Government is committed. The Welsh Government Wales. will be bringing forward legislation on sustainable
Figure 8: The Health Map
Source: Barton and Grant
15 Chief Medical Officer for Wales Annual Report 2012-13
Table 2: Current issues and future threats to health in Wales Current concerns Future threats Future opportunities Environmental issues • Environmental hazards. • Climate change. Multiagency/multiprofessional • Infectious diseases. • New diseases. working and the imminent review of public services by the end of 2013. Social issues • The inherited burden Health consequences A whole of government, whole of health problems and of existing life of society approach. health inequalities. circumstances and • Variations in services. current behaviours.
Economic issues Current and future consequences of the global Using the health and social care financial crisis, public sector stringency and benefit sector to generate prosperity. reform. Source: Welsh Government Of course, this list is not exhaustive and cannot fully represent the complex interaction between social, Successes environmental and economic factors. However, it • Life expectancy in Wales is increasing. does help to describe some of the issues that must • Healthy life expectancy is increasing. be tackled. • Death rates are falling, especially from circulatory Chapter 2 addresses the environmental and diseases (down by over a third between 2001 health protection issues. Chapters 3 and 4 cover and 2011). social issues; Chapter 3 addresses behavioural and community determinants of health and the opportunities to improve prevention; and Chapter 4 Challenges looks at how services might be refashioned to match • Reducing the prevalence of current unhealthy the circumstances of the 21st century. Chapter 5 lifestyle factors such as smoking and obesity. discusses some of the threats and opportunities the • Preventing avoidable causes of premature death evolving economy presents for Wales. and ill-health including cancers, coronary heart disease, poor mental health and liver disease. • Preparing health and social care services and communities for the requirements of the larger proportion of the population, who will be living longer with chronic conditions and will therefore require healthcare support for longer. • Reducing inequalities.
16 Recommendations
1. NHS Wales, the Welsh Government and partners must continue to build on previous success in improving and protecting the health of the population by ensuring an increase in prevention focussed services and coordinated cross-government action. 2. NHS Wales, the Welsh Government and partners should improve the understanding of happiness and wellbeing in Wales and take action to promote wellbeing. 3. Action to reduce health inequalities should be incorporated into all policies and services with a focus on changing healthy life chances for children.
Source: Visit Wales 17 Chief Medical Officer for Wales Annual Report 2012-13
References 1. Public Health Wales Observatory. Measuring Inequalities: Trends in mortality and life expectancy in Wales. Cardiff: Public Health Wales, 2012. 2. See Data Compendium: www.wales.gov.uk/cmo 3. Welsh Government. Welsh Health Survey 2012. Cardiff: Welsh Government, 2013. 4. See Data Compendium: www.wales.gov.uk/cmo 5. Office for National Statistics.Avoidable mortality in England and Wales, 2011. Newport: Office for National Statistics, 2013a. 6. Welsh Government, 2013. 7. Royal College of Psychiatrists. No health without public mental health the case for action. London: Royal College of Psychiatrists, 2010. 8. Welsh Government. Together for Mental Health: A Strategy for Mental Health and Wellbeing in Wales. Cardiff: Welsh Government, 2012. 9. Royal College of Psychiatrists, 2010 10. Alzheimer’s society. Mapping the Dementia Gap 2012: Progress on improving diagnosis of dementia 2011-2012. London: Alzheimer’s Society, 2012. 11. Australian Institute of Health and Welfare. Risk factors contributing to chronic disease. Cat No. PHE 157. Canberra: AIHW, 2012. 12. Chan M. Opening address at the 8th Global Conference on Health Promotion Helsinki, Finland. Geneva: World Health Organization, 2013. 13. World Health Organization. WHO Global strategy on diet, physical exercise and health. Geneva: World Health Organization, 2004. 14. Vanhala, et al. Relation between obesity from childhood to adulthood and the metabolic syndrome: population based study, 317(7154): 319–320. London: British Medical Journal, 1998. 15. As indicated by the Physical and Mental Component Scores (PCS and MCS) from the SF36 quetionnaire used as part of the Welsh Health Survey. Welsh Government, 2013. 16. Office for National Statistics.General Health in England and Wales 2011 and Comparison with 2001. Newport: Office for National Statistics, 2013b. 17. Office for National Statistics.Health Expectancies at Birth and at Age 65 in the United Kingdom, 2008–2010. Newport: Office for National Statistics, 2012a. 18. Office for National Statistics.Life expectancy at birth and at age 65 by local areas in England and Wales, 2009-11. Newport: Office for National Statistics, 2013. 19. Office for National Statistics.Health Expectancies at Birth and at Age 65 in the United Kingdom, 2008–2010. Newport: Office for National Statistics, 2012a. 20. Foresight. Foresight Mental Capital and Wellbeing Project, Final Project report – Executive summary. London: Government Office for Science, 2008. 21. Layard R. Happiness. London: Penguin Books, 2005. 22. Office for National Statistics.First Annual ONS Experimental Subjective Well-being Results. Newport: Office for National Statistics, 2012b. 23. Currie, et al. Health Behaviour in School-aged Children. 2009/10 International Report: Social determinants of health and well-being among young people. Copenhagen: World Health Organization Region for Europe, 2012. 24. Public Health Wales Observatory. Measuring inequalities: Trends in mortality and life expectancy in Wales. Cardiff: Public Health Wales, 2012. 25. Barton H and Grant M. A health map for the local human habitat. Bristol: The Journal for the Royal Society for the Promotion of Health126 (6). pp. 252-253, 2006.
18 Chapter 2 Protecting the nation’s health
Health protection mitigates the impact of communicable diseases and environmental hazards on the population. It requires first class surveillance, analysis and interpretation of data and the sharing of relevant information across Wales. Once risks are identified they need to be assessed and training needs to be put in place to prevent or control them wherever possible and practicable. Communicable diseases, environmental hazards and extreme weather do not respect national borders. Cooperation across society is essential to minimise impacts and everyone has a role to play in protecting the health of the people of Wales.
Source: Welsh Government Chief Medical Officer for Wales Annual Report 2012-13
Action to ensure safe food, water and environment, As at the end of May 2013, 132 cases of infection together with immunisation programmes to prevent had been reported to the World Health Organization infectious diseases, all help to improve population health. (WHO) including 37 deaths1. The situation is being closely monitored around the world. Health protection is constantly evolving. With easier global travel and migration, the circulation of infectious agents across the globe is much quicker Middle East respiratory than in previous generations, requiring local, UK, syndrome coronavirus European and wider collaboration. New threats (MERS-CoV) are constantly emerging, such as coronavirus in Human coronaviruses, first identified in the mid the Middle East and influenza H7N9 in China, and 1960s, cause respiratory infections of varying others in the chemicals, biological and poisons fields. severity in humans and animals from common colds Re-emerging diseases like anthrax have been seen in to severe respiratory infections. A new coronavirus recent years in Wales and the rest of the UK. was first identified in September 2012 categorised as Middle East respiratory syndrome coronavirus The challenge for health protection in Wales is to remain (MERS-CoV). Most cases have occurred in or have ready to respond to any threat from communicable had a connection to the Middle East. In the period disease and non-communicable hazards. between September 2012 and June 2013 there were 40 deaths from MERS-CoV across the world and four recorded cases in the UK2 ,3. Infection Infection remains a subject of careful interest, because it is essentially preventable and treatable in most cases. New challenges include: • the changing behaviour of organisms, e.g. the worldwide emergence of multiple and extremely resistant strains of tuberculosis; • healthcare associated infections (HCAIs) and anti- microbial resistance; and • growing recognition of the importance of infectious agents in causing and exacerbating life- long conditions.
Recent significant infectious disease threats include avian influenza A(H7N9), Middle East respiratory syndrome coronavirus (MERS-COV) and measles. Avian influenza A(H7N9) China has been reporting human cases of avian influenza A(H7N9) virus infection since the end of March 2013. Despite extensive investigations, the source of A(H7N9) infection in humans is still Source: Crown Copyright unclear, although live animal exposure, particularly to chickens and ducks, is thought to be a factor.
20 Chief Medical Officer for Wales Annual Report 2012-13
Measles The 2012-13 measles outbreak, centred in the Swansea area, attracted considerable attention with over 1,430 notified cases across Wales, 88 hospitalisations and one associated death. Local Health Boards (LHBs), Public Health Wales and other agencies worked together to promote public awareness and offer access to Measles, Mumps and Rubella (MMR) vaccination through a range of settings in community clinics, schools, prisons and healthcare premises. At the declared end of outbreak over 75,000 MMR vaccinations had been administered to individuals at non-routine ages Source: Welsh Government during the outbreak period.4
Some of these vaccinations were early doses, given to babies within the areas most affected by the outbreak, but the majority have been catch-up doses, given to people who had previously missed out on MMR vaccination. More than 20,000 of the catch-up doses were given to children and teenagers aged ten to 18 years. Figure 9 below shows the progress of this outbreak since November 2012.5 Source: Public Health Wales
Figure 9: Notifications of measles in Wales by week Week 44 2012 (week commencing 29/10/2012) – week 26 2013* (week commencing 24/06/2013)
* Data until end of week 26 2013 (17/06/13 - 30/06/13). Data for week 26 is provisional and may increase due to late notifications being received. Source: CoSurv Notifications, Public Health Wales 21 Chief Medical Officer for Wales Annual Report 2012-13
Immunisation The only way to prevent future outbreaks is to ensure herd immunity through a high level of vaccination. For measles, this means at least 95 per cent of children in Wales should receive two doses of the MMR vaccine. The latest figures for Wales indicate that: • the annual uptake of all routine immunisations in one-year-old children for Wales as a whole exceed the 95 per cent target, with 21 of the 22 local authority areas having exceeded the 95 per cent uptake target for the five-in-one immunisation in one-year-olds for 2012-13; • the annual uptake of the first dose of MMR at two years increased to 94.6 per cent, its highest ever level; during the period April 2012 to March 2013, 82.4 per cent of children had completed all recommended immunisations by their fourth birthday; • uptake of the second dose of MMR by five years Source: Public Health Wales of age increased to 89.6 per cent, the highest ever annual uptake of MMR2 at five years of age; uptake of pre-school four-in-one booster in five- year-old children has increased to 91.3 per cent; • uptake of a complete three dose course of human papilloma virus (HPV) vaccine in girls in the routine campaign (2011-12 School Year 8) was 86.6 per cent, an increase of 1.2 per cent compared to the previous year.6
The 95 per cent MMR uptake target at two years of age will probably be reached very soon across Wales. However, MMR uptake in Wales has historically been much lower than this, notably around ten years ago, which allowed measles to spread through susceptible populations.
The simple, cost effective intervention of immunisation protects children and adults from a number of significant illnesses, including protection for those in the community who cannot be immunised. Source: www.istockphoto.com
22 Chief Medical Officer for Wales Annual Report 2012-13
Figure 10: Summary of uptake rates for selected immunisations in resident children reaching their 1st, 2nd, 5th and 16th birthday between 01/01/13 and 31/03/13 and resident on 31/12/12
Source: All Wales Summary – COVER106, Public Health Wales
Figure 11 shows a comparison between Wales’ In the coming year, there will be some changes immunisation uptake and other UK countries. It to the current vaccination schedule, including shows that performance is satisfactory though Wales three new vaccination programmes against flu, falls short of its targets in some cases, and indicates shingles and rotavirus, and an update to the current where further work is needed in Wales. meningitis C vaccine schedule.
Figure 11: Completed immunisations (all antigens) by 12 months and 24 months in the UK by country, 2011-12 Coverage at 12 months Coverage at 24 months % % Country DTaP/IPV/ MenC PCV DTaP/IPV/ Hib/MenC PCV MMR1 MenC Hib Hib booster booster primary UK 95.0 94.3 94.6 96.4 92.7 91.9 91.6 95.1 England 94.7 93.9 94.2 96.1 92.3 91.5 91.2 94.9 Northern 97.5 97.2 97.4 98.4 95.5 93.9 93.3 96.7 Ireland Scotland 97.4 96.8 97.4 98.1 95.3 94.5 94.3 96.1 Wales 95.4 96.1 95.8 97.4 93.7 93.7 92.7 96.0
Key to immunisations Source: COVER7 (Cover of Vaccination Evaluated Rapidly) programme Vaccination Definition DTaP/IPV/Hib Diphtheria, tetanus, acellular pertussis (whooping cough), inactivated polio vaccine Haemophilus influenzae type b vaccination MenC Meningitis C vaccination PCV Pneumococcal conjugate vaccine MMR Measles, mumps and rubella vaccination 23 Chief Medical Officer for Wales Annual Report 2012-13
Sexual health HIV awareness Sexually Transmitted Infections disproportionately raising campaign affect young people, with rates much higher than in There is no room for complacency in respect of HIV. the general population. In 2011, the chlamydia rate In 2010, there were 161 new cases of HIV infection in 15 to 19-year-olds was 541 per 100,000, over four and in total 1,321 Welsh residents were receiving times more common than in the population as a treatment for HIV/AIDS, an 11 per cent increase whole. Between 2009 and 2011 in Wales, there was from 2009. Men who have sex with men continue to a 26 per cent drop in chlamydia infections in 15 to make up a significant proportion of cases in Wales 11 19-year-olds. Rates of gonorrhoea infection in this (49 per cent in 2011). age group decreased slightly between 2009-11 from Research on HIV, hepatitis B and hepatitis C 50 to 44 diagnoses per 100,000. awareness was carried out in 2011 to discover Young people are at increased risk of these people’s knowledge of blood borne viruses and infections, a situation potentially exacerbated how information should best be given. This through the excessive consumption of alcohol and recommended a national HIV awareness raising other substances. Young people who misuse drugs or campaign for Wales. Accordingly, the Frisky Wales alcohol are more likely campaign running in 2012-13 was designed to raise to engage early in awareness in all the population groups, with the aim sexual activity, have of encouraging testing in those who may not self- 12 more sexual partners, identify with specific target groups. be less consistent in use of condoms, and have increased rates of Healthcare associated infections. There are also higher numbers infections (HCAIs) of unplanned Infection as a result of a healthcare intervention pregnancies increases the time a patient takes to recover from associated with this treatment and can lead to severe illness, disability group as a result of or death. their increased risk Source: Welsh Government 8 taking behaviour. In December 2011, the Welsh Government published Commitment to Purpose: Eliminating While more general action is in hand, these preventable healthcare associated infections groups are being particularly targeted through (HCAIs)13 to support suitable and sustainable strengthening links between substance misuse and infection prevention and control. This required sexual health services9,10. a culture shift from ‘control and reduce’ to Generally sexual health services have moved from ‘elimination’ and includes antimicrobial stewardship, ‘consultant delivered’ to ‘consultant supported’ with response protocols and professional culture change. nurse delivered care pathways. However, there are Public Health Wales hosts mandatory surveillance still areas in Wales where access to services should schemes for infections in the blood stream. The data be improved. are used at local and national levels to both inform policy and focus interventions.
24 Source: Public Health Wales Chief Medical Officer for Wales Annual Report 2012-13
Clostridium difficile (C. diff) Staphylococcus aureus There were 1,934 cases of C. diff in Wales in 2012-13, (S. aureus) bacteraemias a reduction of ten per cent compared to 2011-12. NHS Wales achieved a 19 per cent reduction in cases 71 per cent were in hospital inpatients, the rest from of meticillin resistant S. aureus (MRSA) in 2012-13 other parts of hospitals and community locations. compared with the previous year, equating to 38 The main burden of disease occurs in those aged over fewer cases (see Figure 12). However, there was a 65 years who make up 80 per cent of inpatient case 12 per cent increase (77 more cases) in meticillin numbers. sensitive S. aureus (MSSA) bacteraemia in 2012- 13 compared with the previous year. More work is Although LHBs have achieved at least a 50 per cent needed to understand the reasons behind this (see reduction in cases since the baseline year of 2008- Figure 13).15 09, there are still high numbers of cases and variable recent progress, so further focus on implementation is required. Further data were published in July 2013.14
Figure 12: Quarterly numbers of MRSA bacteraemias from hospital patients in Wales, April 2008-March 2013
Source: Public Health Wales
25 Chief Medical Officer for Wales Annual Report 2012-13
Figure 13: Quarterly numbers of MSSA bacteraemias from hospital patients in Wales, April 2008-March 2013
Quarter Source: Public Health Wales
A significant number of HCAIs are related to the use Infection prevention and of medical devices. In 2012, the 1000 Lives Plus initiative 2012 introduced the STOP campaign, control (IPC) aimed at reducing cannula and catheter related Surveillance is an essential part of any effective IPC infections using a care bundle: avoiding unnecessary programme. The Welsh Government is committed use, aseptic insertion and prompt removal16. Success to achieving a Wales-wide electronic system to measures include coordinate data from laboratories with patient reduced usage of information systems to improve the management invasive devices of individual cases as well as outbreaks, local and and reduced national surveillance. This can allow teams to focus incidence of on data analysis and timely feedback to clinicians to bacteraemia. The improve outbreak control, antimicrobial prescribing first Wales national and resistance, and information on surgical STOP day in procedures and medical device insertion. September 2013 will coincide with LHBs are already demonstrating commitment UK Infection to reducing HCAIs but if sustained progress is to Prevention Week, be achieved, they will need to further strengthen when progress clinical leadership within the organisation through will be reported. development of the specialist IPC teams and effective antimicrobial stewardship across primary and secondary care.
Source: Public Health Wales
26 Chief Medical Officer for Wales Annual Report 2012-13
Antibiotic resistance Key findings in the last year show that in Wales: • Escherichia coli (E. coli) is the commonest Antibiotic resistance is becoming increasingly bloodstream infection and incidence is rising; important. It has increased over the last seven years for some of the major pathogens, and is closely • antibiotic resistance in E. coli bloodstream and related to HCAIs. It leads to problems finding urine infections is rising, particularly in the elderly; an effective treatment, failure of treatment and potential complications. New infectious diseases are • the use of antibiotics associated with C. diff has emerging, and older diseases are re-emerging as decreased; and 17 they become resistant to our antimicrobial drugs . • antibiotic usage continues to rise in primary and secondary care; this is a major driver for antibiotic The Welsh Antimicrobial Resistance Programme resistance (see Figure 14). Surveillance Unit provides data to LHBs to guide therapy decisions and to track antimicrobial usage Wales is participating in the development of a new 18 and resistance trends in Wales . five-yearUK Antimicrobial Resistance Strategy and Action Plan19. This will provide surveillance and a coordinated plan of action which are needed to address this issue.
Figure 14: Total antibiotic use (expressed as dispensed items/1000 prescribing units/quarter) in the community across Wales, 2005-12
Source: Public Health Wales
27 Chief Medical Officer for Wales Annual Report 2012-13
Wales-wide population Major environmental screening for early hazards Wales has over 300 industrial sites, including 25 detection top-tier Control of Major Accident Hazards (COMAH) Screening programmes are commissioned by the sites. Accidents involving chemicals stored and Welsh Government for early detection and treatment processed at these sites have the potential to cause of important health problems. There have been recent pollution and health impacts. Unregulated sites, developments. In 2012 Breast Test Wales became the such as illegal waste stores, may also pose pollution first breast screening service in the UK to become fully and health-related risks. digital. In June 2012 parents of newborns were offered screening for medium chain acyl-CoA dehydrogenase Between 2011 and 2013 Public Health Wales deficiency (MCADD) for the first time as part of the responded to 216 serious environmental incidents Newborn Bloodspot Screening programme. Significant with actual or possible public health impacts. Natural progress was also made in developing a new screening Resources Wales recorded over 5,000 pollution programme for Abdominal Aortic Aneurysms. incidents in the same time period, of which 185 The Wales programme now offers screening to were serious and 995 related specifically to air 65-year-old men living in Wales. quality impacts.20
When an incident occurs, robust planning, preparedness and response arrangements are needed to protect public health and the environment. Risk assessment depends on the availability of good quality environmental sampling and monitoring data, and in some instances, modelled pollutant dispersion. Source: Public Health Wales Each Welsh police area has a Local Resilience Forum Uptake rates for the cervical and bowel cancer (LRF) for local multi-agency cooperation to plan and screening programmes are not as good as they could enable an effective response to emergencies. The be. Raising the cervical screening starting age to 25 LRF includes local councils, health organisations, years in autumn 2013 is expected to impact positively emergency services, the Maritime and Coastguard on uptake rates. The gradual decline in bowel screening Agency, Natural Resources Wales, the Animal Health uptake is a particular concern and Public Health Wales Veterinary Laboratory Agency and the Armed Forces. is examining strategies that will encourage further participation. The screening engagement team works with under-represented groups to promote awareness across the range of screening programmes, using a range of media and activities, including promotional events, information literature and more recently, the Source: Public Health Wales development of Facebook pages and A 2012 survey of local resilience fora demonstrated YouTube channels. that roles and capabilities of agencies responsible for incident response environmental sampling and monitoring in Wales could be better understood. The Welsh Government is now leading work to facilitate collaboration to identify solutions to this problem and to develop an overarching plan to manage the public health implications of environmental incidents in Wales. Source: Public Health Wales 28 Chief Medical Officer for Wales Annual Report 2012-13
Air Quality appropriately prioritised action between public health professionals and local authorities to work The quality of the air that we breathe during our life across broader geographical areas since air quality affects our health. High or prolonged exposure to air problems are likely to be shared across boundaries. pollution is associated with significant life-shortening and poor heart and lung health. The Committee Examples of possible areas of work could include: on the Medical Effects of Air Pollution (COMEAP) suggests that 29,000 people die prematurely from • raising awareness of the health impact of poor the health effects associated with air pollution in air quality and encouraging individual and the UK each year21. Removing all fine particulate community lifestyle adaptations and behaviour air pollution could have a bigger impact on life changes to reduce exposures and risks e.g. expectancy than eliminating passive smoking or reduction in use of cars; road traffic accidents22. The economic cost from • promoting the services available to help air pollution in the UK is estimated at £9-19 billion individuals make healthier choices, e.g. early every year, which is comparable to the economic warning systems which allow particularly cost of obesity (over £10 billion)23. vulnerable individuals to take action to reduce The increasing awareness of the impact of air exposure to elevated air pollution such as staying indoors; pollution (measured at PM2.5), on health has led to the development of new measures and estimates of • tailoring information for susceptible groups; the burden of air pollution on the local population24. This year, COMEAP, supported by Public Health • raising awareness that tackling air quality would England and the Institute of Occupational Medicine, improve healthy life expectancy and reduce early has generated estimates of the local health death from cardio-respiratory diseases; and impact of fine particulate air pollution using these • integrating air quality into other public health new measures for England, Scotland, Wales and initiatives such as active travel schemes, transport Northern Ireland. These estimates, provided at plans and cycle to work schemes. local authority and LHB level for Wales, will provide a real opportunity for stronger collaboration and
Case study – airAware airAware is a two-year pilot project in Neath Port Talbot. The study, a first for the UK, aims to evaluate the effect of informing patients of the need to take preventive action during episodes of poor air quality. It uses a real-time alerting system based on routinely collected air quality data and defined health-based triggers. Patients with respiratory or coronary heart disease were invited by their GP to join the project. Evaluation is underway in conjunction with Swansea University using qualitative and quantitative methods, including tracking of GP and hospital contacts.25
29 Chief Medical Officer for Wales Annual Report 2012-13
Air pollution levels across defined geographies vary, Climate change and due mainly to the different sources of pollution in and around a given area, but also because of extreme weather events influences from further afield. An environmental Our climate is changing and evidence suggests justice analysis of British air (NO2) concluded that that more extreme weather events and sometimes “those communities that are most polluted and which extreme changes to our climate can be expected also emit the least pollution tend to be amongst the in the years to come. Changing climate will affect poorest in Britain”26. Another review of air quality people’s health, both directly and indirectly. and social deprivation in the UK found that “there Preparing for these changes now should lessen their are specific areas that have the worst air quality and impact, as well as allowing us to capitalise on any are the most deprived, currently and in future years... opportunities arising from such a change. To help a disproportionate number of some of the most coordinate the public health response, the Welsh vulnerable members of the community also live in Government established a Climate Change and these areas”27. Health Working Group to develop a Climate Change and Health Action Plan. Further research is needed to gain a greater understanding of the relationships between During the 21st century, as detailed in the UK variations in pollution levels and health and social Climate Projections 2009 (UKCP09)28, Wales may outcomes at the local level. An appreciation of the experience increasing average temperatures relative effectiveness of interventions to reduce throughout the year, an increase in average rainfall levels of air pollution and bring about health gain is in winter, a decrease in average rainfall in summer also required. Findings from this work should, in turn, and rising sea levels. The UK Climate Change Risk inform future policy development with associated Assessment: Government Report29, published in measures to evaluate impacts. January 2012, considered the main opportunities and threats for Wales that may result from these changes in climate.
30 Source: Visit Wales Chief Medical Officer for Wales Annual Report 2012-13
Source: Welsh Government In 2013, the Welsh Government published statutory fires across Wales, heavy snowfall and freezing guidance for public services on Preparing for a temperatures. Extreme weather events now receive Changing Climate30. It assists organisations, such more attention than previously. as local authorities and health services, to assess how they may be affected by climate change and The impacts of these events range from acute to produce plans to manage it. Vulnerability to climate chronic health effects and impacts may also be change is manifested by an increase in extreme direct, such as sunburn, or indirect, such as carbon events, such as flooding, storms and gales, changing monoxide poisoning from generators used to pump rain patterns and heat waves. water out of flooded properties. Extreme events need to be monitored. Taking appropriate action In 2012, Wales experienced a number of extreme and building our understanding of the health weather events including flooding in Ceredigion impacts of these events is required to see if lessons and Denbighshire, grassland and mountainside can be learned to ensure future resilience.
Heat wave, Royal Welsh Show 2012 The Royal Welsh Show is held annually at Llanelwedd near Builth Wells in mid Wales. The 2012 show was held during the week of 23 July and covered many of the hottest days of the year. As a result, onsite medical services treated almost 300 cases of heat-related problems including allergies and stings, mild to major sunburn and collapses. Overall, 837 casualties were treated, compared with 485 in 2011, when the weather was much cooler and damper. Source: Visit Wales 31 Chief Medical Officer for Wales Annual Report 2012-13
Aberystwyth floods In June 2012, heavy rain on already saturated land led to flooding of the Ystwyth and Rheidiol Rivers at Aberystwyth. A large number of properties were flooded, as were playing fields and farm land, with some areas under five metres of water. Public Health Wales provided general advice and guidance on the public Source: Public Health Wales health impact of floods, as well as more specific advice around clean-up, coping without mains water, maintaining good food hygiene, storing food, soil contamination, alternative water supplies and use of bottled water, particularly for making up formula for bottle-fed babies.
Lessons learned Successes Protecting the health of the population requires • High uptake of childhood immunisations across concerted and consistent action across a Wales and the HPV cervical cancer vaccination number of organisations in Wales. Threats to programme. health are constantly evolving and preventing • Coordinated response to the outbreak of measles threats becoming problems requires committed, in Wales centred on the Swansea area. professional and well-trained staff. In the coming years it will be vital to support health • Effective ongoing collaboration between public protection professionals and also to create better health professionals, environmental health communication with the wider population in practitioners and other key local government staff. a shared approach. The lessons learned from • Implementation of legislation aimed at protecting the South Wales measles outbreak include the public health including Smoke-free Premises etc. importance of trust and communication between (Wales) Regulations 200731, amendments to the health professionals and the public. In developing Public Health (Control of Disease) Act 198432, the the health protection services of the future, it will Sunbeds (Regulation) Act 201033 and the Food be vital to work in partnership with the community Hygiene Rating (Wales) Act 201334. to reduce the impact of threats to the health of the population. Challenges • A systematic examination of potential threats, opportunities and likely future developments in the medium to long term, to ensure that Wales is ready to respond to any hazards.
32 Recommendations
1. NHS Wales and the Welsh Government must focus their efforts on optimal vaccination rates to create ‘herd immunity’ in order to reduce the risk of outbreaks. 2. NHS Wales and the Welsh Government must play their part, in the UK and globally, to reduce rates of infection, especially HCAIs. 3. NHS Wales and the Welsh Government must develop a strategy to address the issue of antimicrobial resistance. 4. A better understanding of the burden of disease from air pollution exposure at the local level, and reasons for its variation, is needed in Wales. Using this information, agencies should work collaboratively to take evidence- based action locally and evaluate its impact. In turn, evidence generated at the local level should be used to influence national policy where appropriate. 5. The Welsh Government and Public Health Wales should work with local and national agencies, such as the NHS, local government and Natural Resources Wales, to improve community resilience, the provision of public health advice and the implementation of recovery strategies to respond to extreme weather and other natural events. 6. A better understanding of how the risks from extreme weather events and climate change affect health services in Wales is needed. The Welsh Government should work with Local Health Boards to explore these risks and disseminate findings to others, through its Climate Change Knowledge Transfer Programme.
33 Chief Medical Officer for Wales Annual Report 2012-13
References 1. World Health Organization. Human infection with avian influenza A(H7N9) virus – update, 29 May 2013. Geneva: World Health Organization, 2013. 2. World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV) – update, 29 June 2013. Geneva: World Health Organization, 2013. 3. Public Health England. Middle East respiratory syndrome coronavirus (MERS-CoV): update, 7 June 2013. London: Public Health England, 2013. 4. Public Health Wales. Measles outbreak declared over, 3 July 2013. Cardiff: Public Health Wales, 2013. 5. Public Health Wales. Vaccine Uptake in Children in Wales, COVER Annual report 2013. Cardiff: Public Health Wales, 2013. 6. Public Health Wales. Vaccine Uptake in Children in Wales COVER Annual report 2013. Cardiff: Public Health Wales, 2013. 7. The COVER programme collects equivalent coverage data from England, Northern Ireland, Scotland and Wales. UK and country level vaccine coverage statistics are published in the quarterly COVER report in the Health Protection Report on the Public Health England website www.phe.org.uk 8. Tapert, et al. Adolescent substance use and sexual risk-taking behaviour. J Adolesc Health 2011; 28: 181-9. San Diego: University of California, San Diego, USA, 2001. 9. Welsh Government. The Sexual Health and Wellbeing Action Plan for Wales 2010-1015. Cardiff: Welsh Government, 2010. 10. Welsh Government. Working together to Reduce Harm Substance Misuse Delivery Plan 2013-15. Cardiff: Welsh Government, 2013. 11. Welsh Government. Health Statistics Wales 2012, Table 3.8. Cardiff: Welsh Government, 2012. 12. http://www.friskywales.org/ 13. http://wales.gov.uk/topics/health/publications/health/guidance/eliminating/?lang=en 14. Public Health Wales. C.Difficile and S. Aureus Surveillance Report April 2012 to March 2013. Cardiff: Public Health Wales, 2013. 15. Ibid. 16. http://www.1000livesplus.wales.nhs.uk/stop 17. UK Department of Health. Annual Report of the Chief Medical Officer Volume Two, 2011. Infections and the rise of antimicrobial resistance. London: UK Department of Health, 2013. 18. Heginbothom M and Howe R. Antibacterial Resistance and Usage In Wales 2005-2011. A Report from Public Health Wales. Cardiff: Public Health Wales, 2012. 19. UK Department of Health. UK Antimicrobial Resistance Strategy and Action Plan. London: UK Department of Health, 2000. 20. Brunt, et al. Environmental Public Health Wales Annual Review 2012-13. Cardiff: Public Health Wales. Unpublished Draft, 3 July 2013. 21. Committee on the Medical Effects of Air Pollutants. The Mortality Effects of Long-Term Exposure to Particulate Air Pollution in the United Kingdom. London: COMAP, 2009. 22. Miller B and Hurley F. Comparing estimated mortality risks for air pollution with other health risks. September 2007 – Volume 18 – Issue 5 – pp S14-S15. USA: Epidemiology, 2007. 23. http://www.defra.gov.uk/environment/quality/air/air-quality/impacts/ 24. http://comeap.org.uk/images/stories/Documents/Statements/FINAL_Local_mortality_burden_statement_August_2012.pdf 25. http://www.airaware.co.uk/ 26. Mitchell G and Dorling D. An environmental justice analysis of British air quality. Leeds: Environment and Planning A 2003; volume 35: 909-929, 2002. 27. AEA Technology, Air Quality and Social Deprivation in the UK: an environmental inequalities analysis. London: UK Department for Environment, Food and Rural Affairs, 2006. 28. http://ukclimateprojections.defra.gov.uk/ 29. http://wales.gov.uk/topics/environmentcountryside/climatechange/publications/riskassess/?lang=en 30. http://wales.gov.uk/topics/environmentcountryside/climatechange/publications/policystatement/?lang=en 31. National Assembly for Wales. Smoke- free Premises etc. (Wales) Regulations 2007. Cardiff: National Assembly for Wales, 2007. 32. UK Parliament. Public Health (Control of Disease) Act 1984. London: UK Parliament, 1984. 33. UK Parliament. Sunbeds (Regulation) Act 2010. London: UK Parliament, 2010. 34. National Assembly for Wales. Food Hygiene Rating (Wales) Act 2013. Cardiff: National Assembly for Wales, 2013.
34 Chapter 3 Achieving health and happiness through prevention
A person’s happiness and health are closely related. Both are rooted in their social circumstances and many other factors including pre-birth influences. It follows that any attempt to improve things must take into account this complex background, as well as each unique individual’s views. This requires action across government and across society. The analysis of health and wellbeing in Wales in Chapter 1 contained both good and bad news. Life Act earlier, prevent more expectancy and health in general are improving. Chapter 1 illustrated that many health problems are However, there are still inequalities, tough challenges avoidable, if harmful behaviours can be avoided. The such as smoking and obesity and newer threats like liver aim must be to look at the social circumstances that disease, all of which disproportionally affect the poorest make these behaviours prevalent and encourage communities. This chapter focuses on behavioural and people to avoid them. Helping people avoid harmful community determinants of health and what more can habits is an important way to improve health and be done to promote people’s health and happiness. happiness, and the earlier in life the better.
Source: Visit Wales Chief Medical Officer for Wales Annual Report 2012-13
Family relationships matter to health from the very travelled in a car. Exposure to smoke in cars is over beginning1. Early intervention to promote social and twice as likely among children from less affluent emotional development can significantly improve circumstances than more affluent ones8. Wales mental and physical health, educational attainment and has the highest proportion of 15-year-old girls who employment opportunities. Early intervention can also smoke in the UK, although rates are decreasing9. help to prevent criminal (especially violent) behaviour, drug and alcohol misuse and teenage pregnancy2. Smoking rates among all adults have reduced since 2004. Smoking continues to be a major cause of Programmes like Families First provide structured ways health inequalities with adults living in deprived to pre-empt, identify and address problems early, using communities being more than twice as likely to effective interventions3. Joined-up, whole system working smoke (34 per cent) as those living in less deprived is required in order to address these complex issues. areas (14 per cent)10.
Conception, pregnancy, birth and early years provide Urgent work is required to increase the uptake of the foundation for future health and wellbeing for smoking cessation services, especially by pregnant the 35,238 live births in Wales during 2012. Pregnant smokers. Local Health Boards (LHBs), Stop Smoking mothers who have one or more poor lifestyle habits Wales and pharmacy services need to work more increase the risk to their child’s health4. effectively together to achieve this.
Smoking during pregnancy is harmful and remains an In recent years the Welsh issue of concern in Wales, with the highest proportion of Government has taken a mothers in the UK (33 per cent) who smoked before or number of steps, including during pregnancy. Moreover, 16 per cent of expectant legislation, to eliminate mothers continued to smoke throughout pregnancy5. harm through smoking. There remain a number Almost four in ten (39 per cent) mothers in Wales of options for further drank alcohol during pregnancy. Consumption consideration, including levels were generally low, with only two per cent of for example, the use of mothers reporting that they were drinking more than standardised packaging for two units a week on average. Babies’ development cigarettes. is put at risk by the consumption of more than four units of alcohol during a week by a pregnant mother, and the advice from the UK Chief Medical Officers is Alcohol misuse to avoid alcohol altogether6. Wales has the highest alcohol consumption among Source: Welsh Government Rates of smoking and drinking during pregnancy 15-year-olds in the UK, but this is decreasing11. Rates were lower in 2010 than in 2005, but still represent of younger adults (16-44 years) drinking above avoidable harm to children, with higher risk of guidelines and binge drinking have dropped since stillbirth, prematurity and low birth weight7. 2008 (see Figure 15)12.
Lifestyle factors The main harmful behaviours are smoking, alcohol misuse, low levels of physical activity, poor nutrition and substance misuse. Smoking Around 20 per cent of 11 to 16-year-olds report being exposed to smoke the last time they
36 Chief Medical Officer for Wales Annual Report 2012-13
Figure 15: Adults’ alcohol consumption above the daily guidelines, 2008-12*
Source: Welsh Health Survey * adults who drank above daily guidelines at least once in the previous week
Over the next five years, there is a need for a marked Individuals are unlikely to manage this alone. It reduction in the number of people who report will need strong action from the UK Government in drinking above the recommended guidelines and relation to the promotion and price of alcohol, and binge drinking. The actions to deliver this over the licensing. The Welsh Government has responded next couple of years are included in the recently to the recent UK Government consultation and published Substance Misuse Delivery Plan 2013- advocated a minimum price to be set of at least 50p 201513, which outlines the necessary actions to be per unit. It has argued strongly that consideration of taken nationally, regionally and locally to reduce the public health issues should be a condition under the harm associated with alcohol misuse. Licensing Act 2003.
There are a number of programmes in Wales to In addition, the Welsh Government has argued support people to drink sensibly. For example, the that it should have responsibility for the licensing of Have a Word Brief Interventions Programme helps to the sale and supply of alcohol, because the health reduce alcohol misuse by encouraging people to and social harms associated with excessive alcohol think differently about their alcohol use. It prompts consumption impact significantly on services for people to consider making changes to their alcohol which responsibility is devolved. consumption through a simple conversation about drinking habits during a “teachable moment”, i.e. Furthermore, there is a strong case to end the when someone is faced with the consequences of sponsorship of sports and cultural events by their actions and is more likely to be motivated to companies that produce and promote alcohol. change. It also The persistant presence of alcohol advertising is provides skills for unhelpful and alcohol’s impact on people’s lives and safer consumption the harm that can result needs to be reduced14. of alcohol to those who choose to drink.
37 Chief Medical Officer for Wales Annual Report 2012-13
Low levels of physical activity National and local government have vital roles in promoting positive choices through making and poor nutrition available affordable fresh fruit and vegetables, The issue of obesity, both in childhood and later, was creating opportunities for undertaking exercise and raised in Chapter 1. There has been little change in rates providing information and education. Government of physical activity in any adult age group, although can also act across the breadth of its responsibilities younger working-age adults are more likely to be active by using financial tools (e.g. subsidies for healthy on five or more days a week than older adults15. food), legislation (e.g. limit advertising), policy and regulations (e.g. create cycle lanes and footpaths, town planning) and self-regulation agreements (e.g. nutritional labelling of foods).
The Welsh Government will need to continue to invest in initiatives that aim to encourage healthier eating such as Change4Life Wales and the Community Food Co-operative Programme in Wales.
Source: Welsh Government Source: Public Health Wales An important innovation introduced in 2011 is the Child Measurement Programme. This collects Except for people over 65 years, fewer adults are height and weight measurements of all reception eating five or more portions of fruit and vegetables year children, aged four to five, in Wales. It provides a day compared with 2008, with the most deprived consistent data on childhood obesity at local and communities significantly worse than the least national level to measure progress. Results from deprived ones16. the first year of the programme suggest that 28 per cent of children measured in 2011-12 were To achieve the required positive changes in healthy overweight or obese, and 0.6 per cent of children were diets and physical activity levels across all ages, underweight17. Concerted action is needed to increase there is a need for: physical activity levels and improve nutrition. • a cultural shift in how organisations work together; • stronger public service leadership to drive change within public, private and community settings; • a sense of urgency; and • interventions aimed at the whole population using a large scale change model.
Source: Welsh Government 38 Chief Medical Officer for Wales Annual Report 2012-13
Figure 16: Physical activity among adults, 2003-12*
Source: Welsh Health Survey *adults who were active for at least 30 minutes on at least 5 days in the previous week
Figure 17: Fruit and vegetable consumption by adults, 2008-12*
Source: Welsh Health Survey * adults who ate at least 5 portions of fruit and vegetables on the previous day
39 Chief Medical Officer for Wales Annual Report 2012-13
Substance misuse Making real progress There were 137 deaths related to drug misuse in Wales in 2011, a decrease of ten per cent from the – the whole of previous year18. government and the Hospital admissions for mental or behavioural disorders due to multiple/psychoactive drug use whole of society increased by 19.1 per cent (405 admissions) in These problems facing Wales are not unique. 2011 and were at the highest level seen in the last They exist across the whole of Europe and much five years. Admissions for mental and behavioural of the rest of the world. The new World Health disorders due to opioids decreased by ten per cent Organization policy framework for Europe, Health (from 1,351 in 2010 to 1,215 in 2011), reversing 2020, says that to make significant progress the year on year increase of the previous four years. on these action is needed across the ‘whole of Similar change is emerging in referrals recorded government’ and the ‘whole of society’21. on the Welsh National Database for Substance Misuse with a gradual reduction in traditional This view of the pivotal role of government chimes opioid referrals and a growing number of new with the view of the Marmot Review on inequalities referrals for new and emerging psychoactive drugs19. which identified a range of interventions to help people This includes mephedrone which can be readily at every age22. It concluded that reducing health purchased over the internet. inequalities requires action on six policy objectives:
The Welsh Government is responding to these new 1. give every child the best start in life; challenges and the Substance Misuse Delivery Plan 2. enable all children, young people and adults to 2013-15 sets out the actions being taken to reduce maximise their capabilities and have control over 20 the harm associated with substance misuse . There their lives; are a number of actions including a review of the confidential enquiries process into drug related deaths 3. create fair employment and good work for all; and the implementation of an early warning system 4. ensure healthy standard of living for all; on the use of new and emerging drugs across Wales. 5. create and develop healthy and sustainable places The latter will ensure early identification of new and communities; and substances and dissemination of appropriate harm reduction advice and information. 6. strengthen the role and impact of ill-health prevention.
Source: Welsh Government Source: The Marmot Review
40 Chief Medical Officer for Wales Annual Report 2012-13
Action is needed to promote and protect health at Other countries have also taken a cross-government every stage of the life course, particularly for the or whole government approach to address the young. Good parenting and experiencing close broader factors which influence health and bonds in the early years is fundamental to physical, wellbeing. For example the Norwegian Public emotional and cognitive development23. Strong, Health Act26 aims to promote public health and supportive families are crucial in building cohesive reduce social inequalities in health, based on the communities, promoting resilience in children and fundamental principles of health equity, health ensuring good social, physical and emotional health in all policies, sustainable development, ‘the and wellbeing24. precautionary principle’27 and participation.
The Welsh Government The use of these concepts in Wales could generate flagship early years a win-win across the whole of government, with programme, Flying Start, Ministers working together to add value in solving is beginning to have a complex problems. Here are some examples of how positive impact on Ministers could jointly support population health children25. When they go objectives in Wales. to school they are ready to learn and more confident in mixing with other children. Table 3: Joint Ministerial objectives to support population health What the Ministers for Improve employment rates What Minsters for Help employers to improve Economy could do to for disabled people. Health and Social staff sickness rates. improve health Encourage employers to Services could do to Use health technology help staff quit smoking and improve business spending to create new jobs. increase physical activity. What the Ministers for Promote health knowledge What the Minsters Use health premises to Education could do to across the curriculum. for Health and Social promote better skills. improve health Promote healthy food in Services could do to Place a special emphasis on schools and encourage improve education health in the early years. physical activity. Target new skills at deprived communities. What the Ministers for Sponsor ground-breaking What the Minsters Adopt an approach Tackling Poverty could local engagement initiatives for Health and Social of ‘proportionate do to improve health to improve health. Services could do to universalism’.* tackle poverty What the Ministers for Create cycle-friendly policies. What the Minsters Place services in Transport could do to Make roads much safer by for Health and Social communities. improve health creating more 20mph zones. Services could do to Increase use of internet improve transport access for services. Promote car sharing among NHS employees. Source: Welsh Government *This is a term used by Sir Michael Marmot in his work on inequality. He states that to reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage28.
41 Chief Medical Officer for Wales Annual Report 2012-13
There is an important role for legislation in improving health and reducing inequalities. There are many examples where it has been effective, such as promoting health and safety at work and restricting smoking in public places. The restriction of smoking in public places has resulted in reductions in exposure to second- hand smoke, and the number of adult non-smokers reporting being regularly exposed to other people’s tobacco smoke has decreased29.
As Figure 18 shows, people across society can make a contribution.
Source: Welsh Government
Figure 18: A whole of society approach to promote healthier, happier and fairer lives
Source: Based on “Living well across local communities”, NHS North West, 2010
42 Chief Medical Officer for Wales Annual Report 2012-13
The ‘Five Ways to Wellbeing’, referred to in Figure 18, are based upon the most up to date evidence of individual actions that promote wellbeing30. These actions include:
Source: Public Health Wales
interest has developed in ‘health assets’, looking Health assets and at how the strengths already present in people and places can be used to protect and promote health. health literacy These assets have been categorised as ‘the capacity, Recently, public consultations were conducted on skills and knowledge and connections in individuals possible public health legislation and how best to and communities’32. They can be seen as existing at improve public engagement around health. The three levels: feedback has suggested that the Welsh Government and NHS Wales can do a lot more to help people, • the individual, for example resilience, self-esteem, their families and communities to understand what sense of purpose, commitment to learning; is happening to their health, the realistic options • the community, including family, friendship, for change, and what help is available for them to intergenerational solidarity, community cohesion, 31 manage their own health better . religious tolerance and harmony; and In the past, ‘health deficits’ have often been • society: a safe and supportive environment that emphasized, with the focus on what is wrong in can promote physical, mental and social health, communities and an unstated implication that employment security, religious tolerance and solutions must come from outside. More recently harmony.33
43 Chief Medical Officer for Wales Annual Report 2012-13
An assets approach worked well for the Community Health Network programme in the Merthyr Mid-Cluster Communities First area. This programme aims to increase adults’ and children’s levels of physical activity and improve their nutrition, through three distinct areas of work: • the physical activity project – this supports people to make lifestyle changes by providing easy opportunities to take up exercise; • the community nutrition project – helps individuals to identify and express their own food and health needs and develop confidence to make healthier lifestyle choices; and • the community weight project – supports participants to take a long term lifestyle approach to managing their weight and maintaining a healthy Body Mass Index. Source: Welsh Government
This approach of working with the public, also known as ‘co-production,’ has been used in Scotland34. It is Health and wellbeing described in more detail in Chapter 4. across public services ‘Health literacy’ is the ability of people to Public services must take a lead. Local authorities understand and use health information to make already have examples of good practice such as decisions about healthcare issues and their own Wrexham County Borough Council, which issued health. Those with poor health literacy show poorer a planning note indicating that new hot food health and less effective use of healthcare. This is a takeaways should not be located within 400 metres serious concern in Wales35. The Welsh Government of the boundary of a school or tertiary college38. and Public Health Wales need to work together to improve health literacy and the Welsh Government Swansea and Cardiff are members of the World is taking action on literacy generally36. Health Organization’s (WHO) Healthy Cities programme, which stimulates new thinking on New technologies could offer an important health across all local authorities’ activities39. improvement in people’s access to healthcare and advice. Already, 73 per cent of households in Wales have access to the internet, equating to approximately 79 per cent of people aged 18 or over in Wales having home internet access37. Those in more deprived areas are less likely to have access. Source: Cardiff Health Alliance Younger people are more likely to use the internet (95 per cent of those aged under 45, compared with 22 per cent of those aged 75 and over). NHS Wales and the Welsh Government should consider how to provide services by making use of these new possibilities, while safeguarding the interest of those who do not or who may not use the internet in future. Source: Health Challenge Swansea
44 Chief Medical Officer for Wales Annual Report 2012-13
There is an opportunity to extend that way of In 2006, the Countryside Council for Wales asked thinking and working to other parts of Wales, so ‘why is it that 70 per cent of the adult population that any locality could aim to become a ‘healthy of Wales gets insufficient exercise to promote good community’ and focus on working with others for health and wellbeing – costing Wales over £100 their residents’ health. This could be linked to the million per year?’ In response they created a Green Communities First programme to help our most Space Toolkit to help local councils encourage the deprived communities to be healthier. Examples of use of green spaces close to where people live40. This ideas that have been used in those communities has been successfully used by, for instance, Cardiff include time banking and parent support groups run Council and Newport City Council. The National Parks by the people who use them. in Wales Social Inclusion & Child Poverty Strategy and Action Plan 2012-1441 aims to help more people If, as argued earlier, Wales needs to improve levels enjoy the social, cultural and health benefits the parks of physical activity, a broadly based coordinated offer and the Welsh Government is improving routes approach across the entire public sector and and support for walkers and cyclists42. partners is required.
Source: Welsh Government45 Chief Medical Officer for Wales Annual Report 2012-13
A practical manifestation of Wales’ preventive Priorities for prevention approach is the over 50s health check, which will offer everyone over 50 years of age easily accessible across Wales advice on their health and sources of help. This will Improved life chances for all children must continue provide targeted users with greater control over to be a focus. The health sector, with partners, their health and wellbeing, faster access to advice should ensure that it uses all available evidence and services and help overcome problems of health to ‘make every child a healthy child’ through literacy. It will offer individually relevant information a coordinated approach across Wales, from to every person who chooses to use it, employing the conception onwards. A number of elements are latest technology. already in place and work is in hand to strengthen these and connect them into a single plan. This While Wales already has in place a range of will enable the assessment of the health and preventative measures, more can be achieved development of all children in Wales in the first through a systematic and comprehensive approach, three years of life, early identification of potential taking up the example advocated by the WHO problems and prompt intervention as needed. There in its recent framework, Health 2020. That would is an opportunity to change life chances in a only be successful if Wales can mobilise a genuine single generation. commitment across the public sector and real engagement in communities across Wales. The second area of focus is strengthening cross- government work to improve and protect health across the life course. There is an opportunity for the Minister for Health and Social Services to actively Successes seek to establish shared approaches with other • Reductions in smoking among young people. Ministers to achieve a greater impact. • Creation of smoke-free environments. Third is the scope to build on the WHO Healthy • Agreement on a strong set of programmes to Cities idea to develop a ‘healthy communities’ improve children’s chances of good health. approach for the whole of Wales, linked to regeneration. Creating momentum for change requires helping communities to develop confidence and tools to work together to make change happen Challenges at large scale. • Continuing prevention of smoking, especially in pregnancy. Fourth, the Welsh response to the European Union Ageing Well initiative has already gained • Reducing child and adult obesity levels. international attention and deserves to be widely • Raising physical activity levels across Wales. supported. Building on the excellent Welsh strategy for older people and the work of the Older People’s • Strengthening efforts across government and Commissioner, Wales can make a significant society to prevent ill-health. difference to people in their later years43. • Setting outcomes that support joint action by the Legislation can also have an important role in public and services. helping to improve life chances for the long term and prevent avoidable poor health. Through the proposed Public Health Bill, Wales has an important opportunity to explore practical steps which could be taken to make a positive contribution to improving the health of the population.
46 Recommendations
1. NHS Wales, the Welsh Government and partners should ensure there are comprehensive prevention programmes tailored to each stage of life, to: • make every child a healthy child; • keep working age people healthy; and • promote healthy ageing. 2. NHS Wales, the Welsh Government and partners should work collaboratively to develop a strong preventative approach to health and create a momentum for change locally within communities, across government and all public services. There should be ambition to make change at large scale with an initial focus on promoting physical activity and reducing childhood obesity. The Welsh Government’s Commission on Public Services Governance and Delivery should consider how prevention could be fully integrated into the work of all services. 3. NHS Wales, the Welsh Government and partners should use technology to support good health through helping people to acquire greater health knowledge, more control, access to specific advice and services and better health literacy. 4. All Welsh Government legislation should include consideration of how it contributes to better health and wellbeing.
47 Chief Medical Officer for Wales Annual Report 2012-13 References 1. Colman L and Glenn F. When couples part: Understanding the consequences for adults and children. London: OnePlusOne; 2009. 2. Allan G. Early Intervention: The Next Steps. London: Her Majesty’s Government, 2011. 3. http://wales.gov.uk/topics/childrenyoungpeople/parenting/help/familiesfirst/?lang=en 4. Mcandrew, et al. Infant Feeding Survey 2010. Leeds: HSCIC, 2012. 5. Ibid. 6. NHS Choices. http://www.nhs.uk/chq/Pages/2270.aspx?CategoryID=54#close 7. Ibid. 8. Currie, et al. Social determinants of health and well-being among young people. Health Behaviour in School-Aged Children (HBSC) study: international report from the 2009/2010 survey. Copenhagen: World Health Organization Regional Office for Europe, 2012. 9. Ibid. 10. Welsh Government. Welsh Health Survey 2012. Cardiff: Welsh Government, 2013. 11. Currie, et al. 2012. 12. Welsh Government, 2013. 13. Welsh Government. Working Together to Reduce Harm: Substance Misuse Delivery Plan 2013 – 2015. Cardiff: Welsh Government, 2013. 14. Leyshon M. An unhealthy mix? Alcohol industry sponsorship of sport and cultural events. London: Alcohol Concern Cymru, 2011. 15. Welsh Government, 2013. 16. Ibid. 17. Humphreys, et al. Child Measurement Programme for Wales Report 2011/12. Cardiff: Public Health Wales, 2013. 18. Welsh Government. Substance misuse in Wales 2011-12. Cardiff: Welsh Government, 2012. 19. Ibid. 20. Welsh Government. Working Together to Reduce Harm – The Substance Misuse Strategy for Wales 2008-2018. Cardiff: Welsh Government, 2013. 21 . World Health Organization Regional Office for Europe.Health 2020: a European policy framework supporting action across government and society for health and well-being. Copenhagen: World Health Organization Regional Office for Europe, 2012. 22. Marmot, et al. Fair Society, Healthy Lives. London: The Marmot Review; 2010. 23. Heckman J. The Case for Investing in Disadvantaged Young Children in Darling-Hamilton et al, Big Ideas for Children: Investing in Our Nation’s Future. Washington DC: First Focus, 2008. 24. Welsh Government. Strategic Equality Plan and Objectives 2012-2016. Cardiff: Welsh Government, 2012. 25. Welsh Government. Flying Start. http://wales.gov.uk/topics/childrenyoungpeople/parenting/help/flyingstart/?lang=en 26. The Norwegian Public Health Act – institutionalizing action on Social Determinants of Health in Norway. Ministry of Health and Care Services, 2011. 27. Ibid. The guide to the Act explains the principle as follows – If an action or policy has a suspected risk of causing harm to the public or to the environment, the absence of scientific consensus that the action or policy is harmful, cannot justify postponed action to prevent such harm. 28. Marmot M. Fair Society, Healthy Lives; The Marmot Review – Strategic Review of Health Inequalities. London: The Marmot Review, 2010. 29. Public Health Wales Observatory and Welsh Government. Tobacco and Health in Wales. Cardiff:Public Health Wales Observatory and Welsh Government, June 2012. http://www.wales.nhs.uk/sitesplus/922/page/59800 30. Aked, et al. Five Ways to Wellbeing: A report presented to the Foresight Project on communicating the evidence base for improving people’s well-being. London: New Economics Foundation, 2008. 31. Consultations on the need for a Public Health Bill in Wales and on the People’s NHS; details are on the Welsh Government website at http://wales.gov.uk/consultations/healthsocialcare/?status=closed&lang=en 32. McLean J. Asset based approaches for health improvement: redressing the balance. Briefing Paper Concepts Series 9. Glasgow: Glasgow Centre for Population Health, 2011. 33. Morgan A and Ziglio E. Revitalising the evidence base for public health: an assets model 14:17. Promotion and Education, 2007. 34. Scottish Government. Health in Scotland 2010 Assets for Health: Annual Report of the Chief Medical Officer. Edinburgh: Scottish Government, 2011. 35. Puntoni S. Health Literacy in Wales: A scoping document for Wales. Cardiff: Public Health Wales, 2011. 36. Welsh Government. Programme for Government. Progress Report Education. Cardiff: Welsh Government, 2012. 37. Welsh Government. National Survey for Wales: Headline Results, April 2012-March 2013. Cardiff: Welsh Government, 2013. 38. Wrexham County Borough Council. Local Planning Guidance Note No 9 - Hot Food Take-Aways. Wrexham: Wrexham County Borough Council, 2011. 39. http://www.healthycities.org.uk/ 40. Countryside Council for Wales. Providing Accessible Natural Greenspace in Towns and Cities. A Practical Guide to Assessing the Resource and Implementing Local Standards for Provision in Wales. Cardiff: Countryside Council for Wales, 2004. 41. National Parks in Wales. National Parks in Wales Social Inclusion & Child Poverty Strategy and Action Plan 2012-14. Cardiff: National Parks in Wales, 2012. 42. See proposed Active Travel (Wales) Bill. National Assembly for Wales, 2013. 43. http://www.olderpeoplewales.com/en/Home.aspx
48 Chapter 4 Creating safe and resilient 21st century healthcare services
Everyone will need the NHS at some point in their lives and it must remain resilient in the face of change. So the NHS must continuously refashion itself. It must become more open, working ever more closely with the public and the community to prevent and treat poor health and improve people’s lives. Above all, it must focus relentlessly on quality as its central concern, exploiting innovation and the latest technology. Many of us appreciate the help and support we treated with dignity and respect. Some 92 per receive as individuals from the NHS when we need cent of people were satisfied with the care they healthcare. The National Survey for Wales (2012- received from their GP, and 90 per cent of people 13)1 showed that 96 per cent of people who saw were satisfied with the care they received at a NHS a GP or had a hospital appointment felt they were hospital.
Source: Welsh Government Chief Medical Officer for Wales Annual Report 2012-13
These responses indicate that NHS Wales is valued. While not everything is right, the aim must be to The changing nature of consolidate and improve on this level of trust. NHS Wales in the 21st century should be founded on the Welsh health system quality, driven by effective clinical leadership, with Change is constant and inevitable. Figure 19 shows people, communities, health professionals and dramatic shifts in the Welsh health system over the government working together to secure good health. past 40 years. The population rose by 12 per cent, and the number of inpatients has substantially This chapter focuses on how well Wales is succeeding increased, but changes in treatments and practice in providing everyone with health services which are have led to a reduction in average length of stay. In genuinely compassionate, safe, effective, reliable primary care, the average GP list size has reduced and work well with other services – especially social by almost a quarter. Other changes include the services and the third sector. It also looks at what new medicines available, advances in imaging and more needs to be done. diagnostic tools and changes in the makeup of the clinical workforce.
The changing population, evolving evidence and new technologies mean that the answers of 1970 are unlikely to hold true in 2013 and beyond. The 21st century NHS in Wales must anticipate need and create resilient services.
Figure 19: The change in the health system in Wales over the past 40 years*
Source: Welsh Health Trends 2011 * since 1970
50 Chief Medical Officer for Wales Annual Report 2012-13
unnecessary admissions and re-admissions, longer The impact of 3 population change lengths of stay and unfavourable patient experience. Population changes have a growing impact Staff working in the NHS in Wales report that they on healthcare demand. Wales has the highest feel they do not have time to carry out all their work, proportion of over 85-year-olds in the UK – a pattern though more positively, over eight in ten feel their that will increase over coming years2. role makes a difference to patients 4.
Poor health status and persistent social and geographic inequalities are also representing major factors driving demand.
In general hospital settings, people aged over 65 years currently account for 70 per cent of the total bed days and 25 per cent of inpatients have dementia. This situation is mainly due to a longer life expectancy in the general population. Hospitals and healthcare staff roles are not always specifically tailored for this ageing population, resulting in
Source: Welsh Government
Figure 20: Number of attendances and attendance rate per 1,000 population at major A&E departments in Wales by age, 2012-13*
Source: Emergency Department Data Set
* Attendances for those aged 90 or over and where age is unknown are not included. Data may be subject to minor changes. Rates calculated using 2012 mid year population estimates.
51 Chief Medical Officer for Wales Annual Report 2012-13
government, social services and the third sector. Economic factors A solution could be to strengthen integration across The current economic downturn is likely to be these services to use resources as effectively as affecting demand for healthcare through loss of possible and benefit the public. employment, reduced public services and new welfare reforms. The consequences may be poorer diets, This requires all in NHS Wales to look critically at poorer mental health, reduced physical mobility and what they do to ensure care provides the best increased fuel poverty. Examples of the potential outcome and experience for patients and best value health impacts include links with respiratory and for money. The active engagement and support of cardiovascular problems and exacerbation of existing staff is essential to help NHS Wales maintain and conditions, such as asthma, bronchitis and arthritis for improve performance during this period of change. people in reduced economic circumstances.5 In moving forward, Wales has a real advantage in its The impact will vary with people’s circumstances, integrated health service, with a single body in each and specific vulnerable groups, including older area responsible for all aspects of healthcare for its people, children and young people, disabled people, residents. Further development of the primary care women, single parents and ethnic minorities are service is likely to be a key development. likely to be particularly affected. Unemployment is linked to poorer health, mental health being most affected in an economic downturn.6 A relentless How much to spend on focus on quality healthcare? Wales needs a health system created to deliver only Demand for healthcare is growing at a time when high quality and high value care. Excellent clinical it is increasingly difficult for government to find care is not only better for patients but good for additional resources, not just in Wales, but across the whole system, and often costs less. Staff who the UK and beyond. This is also true of other feel pride in their service provide a better patient services that work alongside the NHS such as local experience. Services should be safe, effective and
Source: Crown Copyright 52 Chief Medical Officer for Wales Annual Report 2012-13
compassionate and should meet the needs of patients, while treating them with dignity and respect. Safety must be the core concern.
Paying attention to what patients say is fundamentally important in improving the quality of care and this is becoming more systematic. The Welsh model for managing the quality of healthcare is built around clear standards, checks within NHS organisations and by external regulators, and careful monitoring. There are a number of interlocking mechanisms in place to provide assurance that everyday services are of good quality and to Source: Crown Copyright promote service improvement7. In addition, the reduced the occurrence of pressure sores and Welsh Government is currently implementing a healthcare acquired infections, but this is not strategy to improve both transparency and accuracy happening everywhere in Wales. There remains a of data about NHS services in Wales; patients and need to emphasise a relentless focus on quality in clinicians are being involved to help achieve a every patient contact and ensure its delivery. consensus on what is required.
To improve the effectiveness of the main areas of clinical practice such as heart disease, cancer and mental health, the Welsh Government is publishing service-specific delivery plans8. These set out action required to meet the needs of local people, encompassing lifestyles, prevention, self care and general and specialist care. Clinical staff and patient groups have helped develop the delivery plans and work out how best to measure progress.
The events at the Mid Staffordshire NHS Foundation Trust and subsequent review by Robert Francis QC9 have provided a catalyst for action in Wales. Source: Public Health Wales These events challenged every aspect of a system which should have been there to protect patients and ensure the highest standards of safe and Clinical staffing and compassionate care. Francis’ findings reinforce that NHS Wales must never be complacent and assume leadership that such failures were merely a feature of Stafford It is essential to employ adequate numbers of Hospital. Consequently, an assessment has been appropriately trained staff. The Wales Medical and undertaken of the actions set out in the Francis Dental Academic Board is currently considering how report and their applicability to NHS Wales. There best to develop the workforce and ensure that Wales is will be constant monitoring of the issues raised by able to secure excellent staff. There is an opportunity Francis and NHS Wales should be proactive to ensure for Wales to identify, nurture and use its distinct quality and safety are the paramount drivers of care strengths to attract and develop the best talent. and patient experience. Strengthening of the NHS workforce requires In addition, clinical teams across Wales are engaged strong clinical leadership, which is fundamental for in implementing the 1000 Lives Plus initiatives on promoting high quality and high value care. Effective improving aspects of care10. The results can be involvement of clinicians in leadership roles can be impressive with, for example, some units having taught and learned and improves patient outcomes 53 Chief Medical Officer for Wales Annual Report 2012-13
and the culture of the whole health system11,12. Wales is building a common way of developing A partnership with the public service leaders to strengthen consistency and integration across agencies and spread necessary public – co-production service change, and it is vital that leaders in clinical ‘Co-production’ is a concept that is increasingly areas also acquire these skills and aspirations. Wales being discussed and applied. It refers to can create a unique system of peer led, self critical, collaboration between those who provide services high value healthcare. These are important areas for and those who use services to ensure they are focus over the next few years. better and more effective. In relation to healthcare, co-production makes use of both clinicians’ and patients’ expertise: clinicians in medical science and techniques and patients in understanding their own Fair and flexible situations and circumstances. Open engagement where both parties contribute and are respected can healthcare draw out the best from both sides.14,15 In 1972 a Welsh GP, Dr Julian Tudor Hart, observed that those most in need of healthcare were least likely Patient involvement with to get it13. Since then serious efforts have been made health services to tackle this ‘inverse care law’. • Only five per cent of people strongly agreed Universally, good access to healthcare should start that they felt well informed about how their at primary care – usually the first point of contact for local health services were performing, with 19 health services. A community profile at local area level per cent tending to agree. has clarified community needs for GP practices. This allows identification of the most socio-economically • 58 per cent of people wanted more deprived areas, enabling better local prioritisation. By information on performance. the end of 2013, two areas will have carefully designed • Only two per cent of people strongly agreed action plans in place to tackle the inverse care law, so and 12 per cent tended to agree that they that better services do more to manage the causes of were able to influence the decisions made by problems like heart disease. The Welsh Government their local health service. will monitor their success and the lessons that can be drawn more widely in helping to tackle the inverse • Over two fifths wanted to be more involved in care law more generally. Work to review whether NHS those decisions. resources are allocated fairly across different areas will Source: National Survey for Wales 2012-13 be carried out in the near future. To work, co-production requires a shift in the power Besides preparing delivery plans for current major balance away from the people who traditionally run diseases, the Welsh Government and NHS Wales also the system, the professionals and managers, towards need to be alert to emerging problems. Liver disease is service users. Time and training are needed to help becoming a bigger concern through several underlying adopt a new role, with the potential benefits for service causes linked to social deprivation, such as alcohol users being more control over their own health and misuse, obesity and hepatitis infection. This complex wellbeing, and for clinicians greater job satisfaction. issue needs a fresh look and a delivery plan should be developed to ensure the right services are in place An example might help illustrate the issues, such across Wales now and for the future. as giving a patient an electronic device for remote monitoring of a chronic condition. The benefits Two other issues that require action to ensure services would be far greater sensitivity to changes in the adapt and develop to accommodate the rising demand clinical condition and a reduced need to travel. Some are the increasing rates of diabetes related to obesity patients might more easily accept this than others, and dementia linked to population ageing. More but all might need to learn new skills and take on new emphasis on prevention and primary care services will be responsibilities. needed to cope with these future challenges. 54 Chief Medical Officer for Wales Annual Report 2012-13
As services change, people are more likely to trust and use the new arrangements if they have a A health service for the chance to influence their design and management. The results are likely to be much better if the public 21st century – balanced are helped to look after their own health as well as and innovative possible and use the NHS more effectively. NHS Wales needs to be forward-looking and agile There are opportunities to apply this thinking at all to respond to the changing profile of the country stages in the healthcare process, for example: and its people. It cannot simply hope to respond to changes as they happen. There needs to be more • improving availability of clear, understandable preventative and anticipatory thinking and effective information on health and services, using a variety use of developing technology. of the latest social media as well as traditional approaches; Action to protect and improve health can prevent or delay the need for expensive, complex interventions. • getting people more involved in planning The aim is a health system that involves the Welsh health services; Government, businesses, communities and people • making real time data publicly available so people working together, each playing a full role in helping to can comment on the services they use and receive keep people fit and healthy by understanding what a response; affects health. Every contact with services should be seen as an opportunity for prevention. The Social Services • giving people more say over realistic treatment and Well-being (Wales) Bill17 now being considered by and care options; and the National Assembly for Wales will help make this shift, • giving people more control in managing their by putting a strong emphasis on prevention and early own care. intervention by social services and NHS Wales to help stop problems occurring or getting worse. There are already good examples of this in practice in Wales and these ideas have been applied over Despite successful prevention, there will always be a several years in the field of mental health services. need for high quality services that deal quickly and The MAGIC Programme (Making Good Decisions effectively with health problems as they arise. These in Collaboration)16 is a good example of working include supportive first line care with expert local closely with the public around new ways of involving clinical back-up able to restore people quickly and people in their own care. It is operated by Cardiff effectively to fitness, or to refer them to appropriate and Vale University Health Board and funded specialist care. by the Health Foundation. In collaboration with Service users expect to see a system of integrated Cardiff University, the programme shared decision- care that involves public services working as one, not making in various community and hospital settings. as separate components. This means NHS Wales Several clinical teams are using quality improvement working effectively with social services and every techniques to redesign, test, evaluate and establish other organisation that can support people when the best ways to embed shared decision-making as they need help. Examples of this thinking in action part of routine practice. This work demonstrates that include the Gwent Frailty Programme18 and the it is possible for services to change fundamentally and Wrexham Intermediate Care Service19, which draw improve outcomes. Greater involvement of the public on the combined resources of NHS Wales and local and service users could help accelerate improvement social services to help people remain living ‘happily across the health system. independent’ as long as it is safe for them to do so.
Source: Crown Copyright
55 Chief Medical Officer for Wales Annual Report 2012-13
Future Chief Medical Officer for Wales Annual Reports could track progress against these objectives by monitoring whether increasingly:
1. people are able to access simple, clear information about the availability and performance of their local health services;
2. people can feed back their views on the care they receive; and
3. clinical standards throughout Wales are improving, measured by safer care with fewer infections and clinical errors. Source: Welsh Government
These schemes show how the whole system could work Successes differently, in a more integrated and user-focussed way. • The 1000 Lives Plus campaign in place across Wales. Building on local community assets and the co-production model must be components of a new • The delivery plans in place for major diseases. approach. This will require managers and staff to be alert to and interested in the user perspective, and provide information on service availability and performance and open communication channels to make it work. The Challenges benefits in return will be keeping people healthy and • Making a significant shift in creating a true aware of health issues, keeping services responsive and partnership between NHS Wales, the public, relevant and assuring their quality. patients and clinicians. • Integrating services in a way that uses resources to best effect and gives the best results for Looking forward service users. Health services inevitably will change in the coming • Building on the strengths of NHS Wales to attract years, and the challenge will be to maintain and the best clinicians and managers. improve quality. Partnership with the public is important and potentially easier than ever before. • Reorienting health services towards those in The next few years could see a health communications most need. revolution in Wales drawing on the new technologies now available to many people. These can provide people with information and advice and also gather their views about health and services.
56 Recommendations
1. NHS Wales and the Welsh Government should ensure a relentless focus on quality and safety to underpin the whole healthcare system, ensuring that systems of care are centred on the importance of the clinician-patient relationship. 2. NHS Wales and the Welsh Government should ensure that action on prevention is embedded across the healthcare system. 3. NHS Wales and the Welsh Government should ensure that the approach to healthcare constantly adapts to meet the needs of the 21st century, for example, through effective use of technology and rebalancing the role of specialised services and care delivered in communities.
57 Chief Medical Officer for Wales Annual Report 2012-13
References 1. Welsh Government. National Survey for Wales: Headline Results, April 2012-March 2013. Cardiff: Welsh Government, 2013. 2. Office for National Statistics.Population Ageing in the United Kingdom, its Constituent Countries and the European Union. Newport: Office for National Statistics, 2012. 3. Royal College of Physicians. Hospitals on the Edge? The Time for Action. London: Royal College of Physicians of London, 2012. 4. BMG Research. NHS Wales Staff Survey 2013 – National Overview. Birmingham: BMG Research, 2013. http://www.wales.nhs.uk/nhswalesstaffsurveyresultspublished. 5. Winters, et al. Assessing the Impact of the Economic Downturn on Health and Wellbeing. Observatory Report Series No. 88. Liverpool: Liverpool Public Health Observatory, 2012. 6. Ibid. 7. Welsh Government. Safe Care, Achieving excellence – The quality delivery plan for the NHS in Wales 2012 – 2016. Cardiff: Welsh Government, 2012. Welsh Government. Safe Care, Compassionate Care: A National Governance Framework to enable high quality care in NHS Wales. Cardiff: Welsh Government, 2013. 8. The Welsh Government has issued delivery plans for the following services: cancer, heart disease, stroke, mental health, end of life care, oral health, maternity services, critical care, achieving excellence – quality delivery, diabetes and eye health care. These are scheduled to be issued during 2013: respiratory care and neurology http://wales.gov.uk/topics/health/publications/health/strategies/?lang=en 9. Francis R, QC. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Mid Staffordshire NHS Foundation Trust. London: The Stationary Office, 2012. 10. 1000 Lives Plus http://www.1000livesplus.wales.nhs.uk/ 11. Dickinson H and Ham C. Engaging doctors in leadership: review of the literature. Birmingham: University of Birmingham Health Services Management Centre, 2008. 12. Bohmer R. Clinical leadership for service improvement. London: Presented at The King’s Fund 2012 Leadership Review lectures, 2012. 13. Tudor Hart J. The availability of good medical care tends to vary inversely with the need for it in the population served. London: The Lancet, Volume 297, Issue 7696, 1971. 14. Realpe A and Wallace L M. What is co-production? London: The Health Foundation, 2010. 15. Dunston, et al. Co-Production and Health System Reform – From Re-Imagining To Re-Making, The Australian Journal of Public Administration, vol. 68, no. 1, pp. 39–52, 2009. 16. See http://www.cardiffandvaleuhb.wales.nhs.uk/Magic 17. National Assembly for Wales. Social Services and Well-being (Wales) Bill, c2013. Draft. Cardiff: National Assembly for Wales, 2013. 18. http://www.gwentfrailty.torfaen.gov.uk/ 19. www.wales.nhs.uk/sitesplus/829/opendoc/174299
58 Chapter 5 Acting on the relationship between health and wealth
The economy depends on a healthy population and a healthy population relies on a sound and fair economy. Understanding and acting on this interdependence is essential to improve wellbeing over the longer term. NHS Wales and its partners already do a great deal to support people to enter and stay in employment through tackling ill-health. However, Wales could still do more to use the huge investment in the health and care sector to support employment, innovation and prosperity. There is a well defined relationship between the health of the economy and the health of the The economic challenge population. A healthy population, including healthy There are three major economic issues facing Wales older people, is good for economic growth and with the potential to impact adversely on health, productivity, and can contribute very substantially namely long-term structural poverty and deprivation, to the economy. People with poorer health are less the impact of the economic downturn and the likely to be working and, if in work, are more likely impact of benefit reform. to have reduced productivity. There is significant evidence suggesting that poor health reduces 1 Long-term structural poverty economic growth. and deprivation This chapter further explores the links between The emerging evidence over the past decade of the health and economic growth and development. impact of the social determinants of health helps to It also explores possible action by the Welsh explain the continuing problem of poor health and Government, local authorities, NHS Wales and slower health improvement in Wales. An communities to improve health and wellbeing. There international panel of experts explored the way is scope for greater use of the health and care sector health is affected by people’s individual as an economic generator for promoting biomedical circumstances and demonstrated that poor health innovation, skills and employment – particularly in results from restricted access to health-improving the social care sector, which is likely to grow with an resources – good education, strong social networks, ageing population. a clean environment, work and financial resources. Estimating the cost of unhealthy behaviours Essentially, poor access to in Wales resources causes poor • NHS Wales, social care and informal care of health.6 mental health was estimated to cost in excess of £1 billion in 2007-082. Even though the unequivocal evidence to • Smoking is estimated to cost NHS Wales over substantiate this link has £386 million per year3. only recently emerged, the link between poverty, • Obesity and excessive alcohol consumption deprivation and health together cost an estimated £140 million per year4. has formed an enduring • Physical inactivity is estimated to cost the nation Source: Welsh Government 5 more than £600 million per year . 59 Chief Medical Officer for Wales Annual Report 2012-13
theme of Welsh Chief Medical Officers’ reports for Negative impacts on health might arise directly from at least 30 years. To improve health and wellbeing a number of reasons including reduced income due for everyone in Wales in the future, structural to the benefit changes, tougher sanctions including levers must be used to tackle the root causes of ill- additional waiting periods for benefit eligibility and health and poor wellbeing. The cumulative effects migration of claimants into cheaper, poorer-quality of poverty on health and wellbeing are widely and possibly overcrowded housing. Again, these understood and the Welsh Government’s Building might be offset (to some extent) by the positive Resilient Communities: Taking Forward the Tackling effects on health associated with employment.12 Poverty Action Plan7 explicitly addresses the need for action to support people facing poverty8. Impact of the What can be done about economic downturn the challenges? When Wales first entered the economic downturn the Poverty is currently harming health, and the impact possible impacts on the health of the population were may worsen, at least temporarily, with the continued predicted to be job losses, higher unemployment, economic downturn and benefit reform. Poor health in associated insecurity and uncertainty, increasing turn places a significant burden on the economy. The financial strain, stigma and loss of mental wellbeing9. challenge is whether Wales can create a beneficial cycle These effects can be expected to be felt even more where better health supports a prospering economy in the areas and communities which felt the impact that in turn generates good health. of deprivation and poverty long before the current economic problems. A key to this may be through making the health and social care sector in Wales an engine for growth, There is a time lag in the data before the harmful impact with benefits for both health and wider prosperity. of the recession and austerity on health becomes The health and social care sector was one of the clear. Other parts of Europe are already showing a link largest components of the Welsh economy in 2010, between economic downturn and increased incidence of representing 11 per cent of Gross Value Added (GVA) suicide10. It is not possible at present to identify whether and was second only to the manufacturing sector there is a similar pattern of suicide in Wales, and this in size13. In that year the health and social care should be examined in the near future. However, what sector accounted for £6.4 billion of annual Welsh does seem to be clear is a very uneven impact of the Government spending (around 42 per cent of the recession, with the gap between the local authorities total). NHS Wales is one of Wales’ main employers with highest and lowest unemployment larger now than with a workforce of 72,00014, plus there are significant in the past eight years. numbers of workers in social care, local authorities and community, third and academic sectors Impact of benefit reform contributing to the health of the population. Wales has a higher dependence on welfare benefits The health and social care sector in Wales has the than the UK as a whole, and benefit reform is likely potential to stimulate growth across the country to cause households in Wales to lose 4.1 per cent and more could be done to strengthen the sector’s of their income (£1,110 per year) on average, economic impact. Two approaches are described here. compared to 3.8 per cent across the UK11. Families The first is to intensify efforts across NHS Wales, the with children are likely to lose proportionately more Welsh Government and society to help people to get of their income compared to pensioner households into work and stay healthy in work. The second is to and working-age households without children. It is build the health and social care economic sector by possible that the welfare policies might have positive supporting ‘health enterprises’ in Wales to develop jobs impacts on health if they lead to more people and skills based on health and wellbeing, in sectors such moving into work. as biotechnology, lifestyle support and social care.
60 Chief Medical Officer for Wales Annual Report 2012-13
Supporting people to get into and stay in work Reducing unemployment in Wales is a key objective for the Welsh Government and is a prime opportunity for cross-government policy. Unemployment deprives people of material comforts, and subjects them to physical and mental stresses. The Welsh Health Survey 201215 shows that there is a gradient in health based on employment status, with those who are long-term unemployed or who have never entered the workforce having the poorest health (see Figure 21). There is a particular challenge around mental health and wellbeing; younger people Source: Wales Council for Voluntary Action unable to get work may suffer harm to their mental wellbeing that can take years to overcome16.
Figure 21: Physical and mental wellbeing, by socio-economic classification of household, 2012
* Physical and mental component summary scores from SF-36 - higher scores indicate better health Source: Welsh Health Survey
NHS Wales and the wider health community are the impact of lower back pain and musculoskeletal working with others to get people fit and healthy in disorders on people of working age in the UK.18 order to give them the best possible chance to enter the workforce. This includes the implementation of Lower back pain is second only to coronary heart the Welsh Government’s Together for Mental Health: disease in reducing disability-adjusted life years Delivery Plan 2012-201617. Removing health barriers (DALYs), a key measure of the impact of poor to employment will be a key challenge in the coming health on the quality and length of life across the years and it is important that NHS Wales is proactive UK. The impact of lower back pain, musculoskeletal and open to working with others in doing so. disorders and neck pain has grown over the last 20 years19. These conditions can be exacerbated in In addition, it is vital that NHS Wales supports the workplace. Workplaces must take responsibility people to stay in work. Part of this is through for preventing these conditions arising, identify identifying and tackling the causes of sickness opportunities for early intervention and support absence and lost productivity. Mental health is a people affected to remain active. major issue, while a recent analysis highlighted 61 Chief Medical Officer for Wales Annual Report 2012-13
Sickness absence from work in the UK • 140 million work days are lost each year due to sickness absence at a cost of around £9 billion to employers; the cost to the economy is £15 billion in lost output. • Most sickness absence is due to mild to moderate mental health, musculoskeletal and cardio-respiratory disorders. • Most people return to work quickly following a period of sickness absence, however, a significant number of absences last longer than they need to. • The longer people are off sick or out of work, the harder it is to get back to work; they become distanced from the labour market and suffer reduced economic, social and health status from being out of work. Source: Public Health Wales • Most sickness absence from work is due to In addition, NHS Wales is looking closely at how it comparatively mild illness which is compatible supports people with long term health problems. The with, and can be improved by work with the aim is to empower people to take greater appropriate advice and support. responsibility for, and control of, their own situation. The Welsh Government is committed to ensuring • Many people with long standing health people with long term conditions have an individual conditions continue to work; in Great Britain, care plan. The planning behind this will entail 26 per cent of people in work have a health professionals working together to look at the full 20 condition or disability. range of issues affecting the individual involved to deliver person-centred, coordinated care and The Healthy Working Wales programme supports support. The focus is on anticipating needs, this aim through initiatives to help employees, providing preventative care and agreeing goals with employers and the health service spot opportunities people to help them manage the impact of their to prevent ill-health becoming a problem. One condition on their day to day lives, such as component, the Corporate employment22. NHS Wales Health Standard, enables needs to develop services employers to progress through that are readily accessible a series of stages that not only and convenient to use to make their workplaces safe, but reduce loss of productivity also actively promote health for those in work with and wellbeing. More than 140 chronic health problems. Welsh employers have received a Corporate Health Standard award, which also helps them see that investment in their working environments can attract a high performing workforce and save on staff Source: Public 21 sickness costs. Health Wales Source: Welsh Government 62 Chief Medical Officer for Wales Annual Report 2012-13
Using regeneration to create to increase the multiplier effects of investment in employment, procurement, innovation and better health and wellbeing capital development. North-west England linked its In addition to supporting people to be healthy, get regeneration programme with health improvement. a job and remain employed, there is also a need to North Rhine Westphalia in Germany created an create better environments for people to live and economic development programme to exploit the work in. Communities First is a community-focused potential of spending on health and care as an programme for tackling poverty, as part of the Welsh economic generator. Their analysis found that in Government’s tackling poverty agenda supporting Germany turnover of the health and care sector, the most disadvantaged people in the most including services, research, training and businesses, deprived areas. equalled that of the motor industry with four times as many employees. It was identified as the most Welsh Government funded Communities First promising sector for future development and the Delivery Teams work with residents, community most rapidly growing sector globally26. organisations, business and other key agencies in selected areas to develop the long term For Wales to take advantage of the circumstances sustainability and wellbeing of communities. As part of the 21st century, a different approach is needed. of the programme, over 100 people across Wales There are two main opportunities to hand. The first are working directly on health improvement activity. is that arising from the link between science and Involving local people in every aspect of its activities technology and the practice of modern healthcare. In addition, NHS Wales is looking closely at how it is an essential feature of the programme, which The second is in the demand for services that will be supports people with long term health problems. The aims to contribute to narrowing the education and generated by the growing number of older people in aim is to empower people to take greater skills, economic and health gaps between our most the population. responsibility for, and control of, their own situation. and least deprived areas.23 The Welsh Government is committed to ensuring people with long term conditions have an individual European Structural Funds offer another opportunity Developing the care plan. The planning behind this will entail to boost the economy and health. Between 2007 and life-science sector professionals working together to look at the full 2013, these injected around £3.3 billion of investment Life sciences and health is one of three ‘grand range of issues affecting the individual involved to (including £1.9 billion from the European Union) into challenge areas’ in the Welsh Government science deliver person-centred, coordinated care and some of the more deprived areas of Wales24. The strategy, and life sciences is a priority sector for support. The focus is on anticipating needs, announcement that Wales will again be able to access economic development in Wales. The Welsh providing preventative care and agreeing goals with European Structural Funds for the period 2014-20 Government has made significant investments in people to help them manage the impact of their presents a further opportunity. In exploring this, NHS supporting research through the Sêr Cymru condition on their day to day lives, such as Wales should look at the learning from other European programme27 and funding the Welsh National Institute employment22. NHS Wales partners, for example the Euregio projects, to see how for Social Care and Health Research (NISCHR)28, and in needs to develop services this funding source can be used to improve and protect supporting business that are readily accessible the health of the population25. growth through the and convenient to use to £100 million Life reduce loss of productivity Sciences Investment for those in work with Fund and other linked chronic health problems. The role of the health initiatives. The and social care sector in establishment of University Health economic development Boards adds another chance to link more Wales should see spending on health not as a closely education, cost but as an investment, following other areas top-class clinical in Europe which have explicitly linked health practice and and economic investment. North-east England economic developed an approach recognising the NHS as regeneration. one of its biggest economic assets, and worked Source: Welsh Government 63 Chief Medical Officer for Wales Annual Report 2012-13
NISCHR is taking steps to support research that improves health, healthcare and patient outcomes and to link research to economic benefits, including commercialisation and the development and protection of valuable intellectual property. Supporting innovation is a core objective, and NISCHR is working closely with the Department for Economy, Science and Transport within the Welsh Government33.
Source: Welsh Government Skills development NISCHR plays a pivotal role in promoting health and Continuing population change will create new social care research in Wales, investing in research challenges and opportunities. For example, in a growing infrastructure and supporting research programmes number of areas in Wales, older people outnumber those and initiatives. Working closely with UK research of working age, particularly in some coastal and rural councils, charities and other key partners, NISCHR is communities attractive to retired people. This presents able to invest strategically to build capacity and a challenge in planning and providing health and stimulate and reward research excellence within Wales. social care, especially as more services are developed in The success of this approach is demonstrated by the community settings. New service models will need to recognition of a number of UK centres of research include careful attention to staff skills and technology for excellence being led from within Wales, such as: remote monitoring and to reduce the need to travel. In addition, there is a need for substantial work on helping • the Development and Evaluation of Complex people to age well and there will also be a growing need Interventions for Public Health Improvement for social care. This may offer an opportunity. (DECIPHer), the UK Clinical Research Collaboration (UKCRC) Public Health Research Linking the need to grow the workforce to a Centre of Excellence in collaboration with the specific commitment that focuses on quality Universities of Cardiff, Bristol and Swansea29,30; potentially offers the triple benefits of creating job opportunities, improving care standards and making • the MRC Centre of Neuropsychiatric Genetics and Wales a recognised centre of excellence in both Genomics at Cardiff University31; and • the Centre for the Improvement of Population Health through e-Records Research (CIPHER) at Swansea University32.
The work of the NISCHR Academic Health Science Collaboration (NISCHR AHSC) has increased engagement between the NHS, academia and industry, strengthening the clinical academic research community in Wales. The launch of Health Research Wales offers key services and support, making it easier to successfully undertake commercial research in the NHS, bringing more economic activity to Wales. It has become easier for research applicants to design studies and negotiate the essential approval procedures, making Wales a more attractive location for clinical trials and studies, offering patients access to the latest trials and better outcomes. Source: Public Health Wales 64 Chief Medical Officer for Wales Annual Report 2012-13
training and service quality. An ageing population is not unique to Wales and will be a focus of interest Harnessing the potential across Europe in the coming decades. In designing Using the health and care sector for economic an integrated health and social care sector to meet growth will be the focus of attention for many specific criteria that offer high value – a focus on countries across the world. The challenge for Wales prevention at every point, co-production with users is to assess the potential and grasp the opportunity and measured quality – there is the possibility of early. Turning this potential into a reality will require attracting people who want to study in Wales and a real commitment from the Welsh Government, exporting training to other places. This will only NHS Wales, clinicians, professionals and the people happen if it is a sector based on the twin pillars of of Wales. It is only by working across the whole of high aspirations and real achievement. government and whole of society that Wales can effectively harness the resources of the health and Beyond the social care workforce, there are other care sector for the benefit of all. sectors that could generate jobs and contribute to improving the health of the population. One is in leisure. There is a need to promote physical activity and combat obesity. Again, if the business sector could be stimulated to address these issues, whether through bootcamps in the park, tai chi or canoeing, there would be multiple benefits. Developing this sector is already a central part of the physical activity strategy, Creating an Active Wales34. Opportunities for NHS Wales and other players to contribute to this objective should be explored further.
Other possibilities Another area where creative thinking might generate a range of benefits is in the use of data contained within administrative systems. The 21st century has been called the ‘information age’ and opportunities which are already at hand need to be explored. Wales has become a world leader in creating techniques to link large amounts of data from different sources to cast fresh light on what is happening to the population or large subgroups of it. The approach screens out any references to individuals so that what is produced describes large anonymous groups, potentially in great detail. The main component is the Secure Anonymised Information Linkage Source: Welsh Government (SAIL)35 programme at Swansea University. There is potential to use this and similar approaches to attract interest from people looking for places to locate large research projects. It might, for example, be possible to develop a research project which included the whole population of Wales as a study group, and with the public as active partners in gaining new knowledge – possibly a modern technological equivalent to the ‘cooperative movement’. 65 Recommendations
1. NHS Wales and the Welsh Government should drive improved health at work by providing support for individuals to maintain healthy lifestyles and designing health services that reduce lost productivity. 2. NHS Wales and the Welsh Government should aim to secure European funding to support economic growth, the regeneration of communities and specifically to improve the health of the population. 3. NHS Wales and the Welsh Government should continue to drive economic development by supporting and sustaining a strong life science sector. NISCHR should ensure its review of programmes focusses on improving prevention and high quality care. 4. NHS Wales and the Welsh Government should develop a distinct health and wellbeing economic sector through appropriate skills development linked to local assets.
66 Chief Medical Officer for Wales Annual Report 2012-13
References 1. See the work of the World Health Organization’s Commission on Macroeconomics and Health (http://www.who.int/trade/glossary/story008/en/index.html) and Commission on the Social Determinants of Health (http://www.who.int/social_determinants/en/). 2. Friedli L and Parsonage M. Promoting mental health and preventing mental illness: the economic case for investment in Wales. Cardiff: All-Wales Mental Health Promotion Network, 2009. 3. Phillips C and Bloodworth A. The cost of smoking to the NHS in Wales. Cardiff: Action for Smoking on Health and British Heart Foundation, 2009. 4. Philips, et al. Assessing the costs to the NHS associated with alcohol and obesity in Wales. Swansea: Swansea University, 2010. 5. Welsh Government. Creating an active Wales. Cardiff: Welsh Government, 2010. 6. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on the Social Determinants of Health. Geneva: World Health Organization, 2008. 7. Welsh Government. Building Resilient Communities: Taking Forward the Tackling Poverty Action Plan. Cardiff: Welsh Government, 2013. 8. Marmot Review Team. Fairer Society, Healthier Lives. London: Marmot Review Team, 2010. 9. Elliott, et al. The impact of the recession on health. Cardiff: Cardiff Institute of Health, Society and Ethics, 2011. 10. Karanikolos, et al. Financial crisis, austerity, and health in Europe. London: The Lancet, Apr 13;381(9874):1323-31, 2013. 11. Welsh Government. ILO unemployment rates by Welsh local areas and year. Stats Wales. Cardiff: Welsh Government, 2013. 12. Welsh Government. Analysing the impact of the UK Government’s welfare reforms in Wales – Stage 2 analysis. Cardiff: Welsh Government, 2012. 13. Statswales https://statswales.wales.gov.uk/Catalogue/Business-Economy-and-Labour-Market/Regional-Accounts/Gross-Value- Added-GDP/LatestGVA-by-Area-Industry 14. Whole time equivalents as at 30 September 2011. Welsh Government, Health Statistics Wales 2012. Cardiff: Welsh Government, 2012. 15. Welsh Government. Welsh Health Survey 2012. Cardiff: Welsh Government, 2013. 16. Prince’s Trust. The Prince’s Trust Youth Index 2013. London: Prince’s Trust, 2013. 17. Welsh Government. Together for Mental Health: Delivery Plan 2012-2016. Cardiff: Welsh Government, 2013. 18. Murray, et al. UK health performance: findings of the Global Burden of Disease Study 2010. London: The Lancet, 381[9871], 997-1020, 2013. 19. Ibid. 20. Black C and Frost D. Health at work – an independent review of sickness absence. London: Department for Work and Pensions, 2011. 21. http://www.healthyworkingwales.com/splash_wales/en.html 22. Welsh Government. Delivering Local Health Care: Accelerating the pace of change. Cardiff: Welsh Government, 2013. 23. http://wales.gov.uk/topics/housingandcommunity/regeneration/communitiesfirst/?lang=en 24. Welsh European Funding Office.European Structural Funds programmes 2007–2013 in Wales. Cardiff: Welsh Government, 2007. http://wefo.wales.gov.uk/programmes/?lang=en 25. See for example the EUREGIO 3 project. http://www.euregio3.eu/ 26. World Health Organization Regions for Health Network. Ten Theses on Regional Health and Wealth. Copenhagen: World Health Organization Regional Office for Europe, 2008. 27. http://wales.gov.uk/topics/businessandeconomy/csaw/sercymruprogramme/?lang=en 28. http://www.wales.nhs.uk/sites3/home.cfm?orgid=952 29. http://www.decipher.uk.net/ 30. http://www.ukcrc.org/researchcoordination/jointfund/publichealth/ 31. http://medicine.cardiff.ac.uk/cngg/ 32. http://www.swansea.ac.uk/medicine/cipher/ 33. Innovation Wales http://wales.gov.uk/topics/businessandeconomy/policy/innovationwales/?lang=en 34. Welsh Government. Creating an active Wales. Cardiff: Welsh Government, 2009. 35. http://www.ehi2.swansea.ac.uk/en/sail-databank.htm
67 Conclusions
This report has taken a very broad view of the achievements, challenges, threats and opportunities relating to health in Wales. Each chapter includes recommendations; progress on these will be discussed in future Chief Medical Officer Annual Reports. Changes in a population’s health sometimes appear The health and social care sector needs to work to move slowly and the economic situation is in more effectively not just with biomedical research some ways challenging. Yet there are opportunities and innovation, the leisure industry and social to make progress. Out of the many issues that care, but other areas such as catering and tourism. this report touches on, three issues could stand as Businesses have the ability to support good health, markers for what needs to happen next, if Wales is to for their own staff and more widely. It is essential see measurable progress over the next five years. for businesses to promote positive behaviours whilst avoiding the endorsement of harmful health First, continued progress is needed on lifestyles. behaviours, for example, the sponsorship of sport by There must be relentless action to reduce the harm alcohol and fast food companies. caused by tobacco and alcohol misuse, which can impact negatively on people’s lives and those Third, because people do get ill and do need around them. Action on obesity is urgent and there healthcare, it is vital that care is as good as possible is growing evidence that physical activity benefits and meets people’s needs and expectations. To both our mental and physical health. Everyone needs ensure this happens people need to feel confident to be more active. that the NHS really cares about them as individuals. Equally, it is vital across the health sector that Second, there needs to be a new approach to there is recognition and adoption of the idea thinking about health and the economy, and how that health is a shared responsibility between the health, healthcare and wellbeing could be developed community, individuals, health professionals and as an economic sector. Chapter 5 shows how NHS Welsh Government. New technologies that allow Wales can get people into work and help to keep more open communications and enable health them in work. It also demonstrates how Wales could professions to understand the individual genetic use investment in good health as a means to grow makeup and the treatment chances of every patient the economy. At this time of economic difficulty, provide new opportunities. it is right to emphasise the huge importance of employment and the economy to health, and to The urgency to seize new ideas and opportunities, encourage Wales to use this as an opportunity to whilst involving people in their own health and think and act differently. healthcare decisions has never been greater.
68