1.2 Poverty and the impact on public health

1.2.1 It is well documented that the broader social determinants of health play a much bigger role in shaping health outcomes than healthcare itself, and addressing the causes of poverty calls for both targeted and universal actions across the social gradient. Action to tackle poverty should therefore feature throughout a range of commitments at a national and local level such as employment programmes, quality housing and access to quality childcare.

1.2.2 Welsh Government had the following key objectives set out in its national action plan for tackling poverty (1):

o To prevent poverty, especially through investment in giving children the best possible start in life. From conception through to early adulthood, the aim is to reduce inequality at the earliest possible stage and break the link between socio-economic disadvantage, educational under achievement and the impaired life chances that flow from these;

o Recognising that the best route out of poverty is through employment, to help people to improve their skills and enhance the relevance of their qualifications. This also involves removing other barriers to employment – from practical barriers such as the accessibility of transport and buildings to less tangible barriers such as poverty of aspiration - helping people to move on to and up the employment ladder;

o at the same time, supporting action to mitigate the impact of poverty – recognising that for more and more people, even being in work will not guarantee that they can escape poverty.

1.2.3 Action in these areas must be taken forward in ways which are mutually reinforcing; good quality, affordable childcare should help children to reach important developmental milestones: at the same time it will create employment for some and remove a barrier to employment for others. Early targeted action to prevent young people from falling out of education, training or employment should benefit them directly but should also benefit the next generation. Advice which helps people deal with debt, or get on-line, should be a basis for enabling them to manage their finances sustainably and use new skills to increase their engagement in work and society. Credit Unions and Time banking can make an important contribution to integrated place based approaches to tackling poverty as can Social Enterprise Development. Gambling regulation improvement especially of fixed odds betting terminals and licencing is needed to avoid clustering of outlets in areas of deprivation. Research on the psychology of Scarcity (2) has shown that poverty affects cognitive processing and decision making adversely in individuals with no previous mental health problems.

1.3 What is the potential role for the NHS in contributing to tackling poverty?

1.3.1 In the CMO report ‘Rebalancing Healthcare; working in partnership to reduce social inequity’ (3) the NHS is highlighted as well positioned to facilitate and empower efforts to work closely with communities and other public sector bodies to directly influence the social, environmental and economic factors which underpin the social gradient and tackle the social determinants of health and well being. Specific recommendations in the report include the provision of upstream effective interventions throughout the life course, with a particular focus on the early years (including the First 1000 Days, Adverse Childhood Experiences, active lifestyle and healthy aging).

1.3.2 The report identified how NHS organisations including Public Health Wales and Health Boards should ensure that health protection interventions are delivered consistently across the social gradient (vaccination, cancer screening, smoking cessation) and how collaboration at primary care cluster level for example, can be used to identify the health and well-being needs of local communities and used to work co-productively with communities to plan, manage and provide services that improve health outcomes and tackle the inverse care law. Local Public Health teams working with Health Board Executive Directors of Public Health are involved in tackling health inequities in partnership with other health professionals and sectors. Examples include involvement in Valleys Taskforce and Cwm Taf and ABUHB Inverse Care Law work.

1.3.3 Patient outcomes depend not just on the clinical care and treatment offered to people but on the wider aspects of a person’s life- whether they work; what job they have, their living conditions and finances; their family life. These factors should be of interest to every professional seeking to maximise the impact of their work as clinical outcomes are likely to be improved by attention to these pressures. Primary Mental Health Care teams and CAMHS services provide essential support to GPs in disadvantaged areas, and some innovations such as GP Support Officers in Merthyr Primary Care cluster have seen benefits to community members with emotional support needs.

Befriending schemes for the elderly have been utilised to good effect in particular for older people living in poverty.

1.3.4 Finally, the NHS is the largest employer in Wales. The NHS can be exemplar by providing employment opportunities and by promoting good employee health and well-being, reducing sickness rates and leading the way on pay equality and providing good-quality and stimulating work.

1.4 Actions taken by Public Health Wales to progress implementation of the WFG Act and support for Public Services Boards

1.4.1 Public Health Wales takes a positive view of placing sustainable development on a statutory footing through the WFG Act and as a new potential opportunity to change the landscape for future generations.

1.4.2 Public Health Wales is a partner in Cymru Well Wales, a collaborative undertaking involving different sectors. It was set up address challenges such as persistent health inequities and the financially unsustainable health and social-care system, with a focus on the broader determinants of health. Three priority areas of work have been identified: the first 1000 days, ACEs, and employability.

1.4.3 Public Health Wales have taken this opportunity presented by the new legislation to invest in a Health and Sustainability Hub to help both the organisation and the wider NHS system respond to the WFG Act in order to maximise opportunities for improving health and well-being and reduce inequity.

1.4.4 Whilst Public Health Wales and the Hub do not provide support to the Public Services Boards (PSBs) on an individual basis, the Hub provides support to the public health community in its various roles on PSBs with the following aims:

o Bring together Public Health colleagues from across Wales who are supporting the PSBs through a PSB Support Network, to share information about work underway in different PSB areas;

o Ascertain the level and type of support which the Hub can provide to Network members.

1.4.5 The Hub in Public Health Wales has delivered workshops for the PSB Support Network covering themes like the use of evidence and leadership qualities for working with PSBs, with up-dates from the Office of the Future Generations Commissioner, Wales Audit Office and senior leaders in Public Health.

1.4.6 As part of the support the Hub is offering to PSBs and the Office of the Future Generations Commissioner, the Hub team have reviewed the PSB Well-being assessments to examine the approach taken to long term thinking and planning for future generations. When published, we anticipate that this report will be useful for policy makers, public bodies and PSBs by identifying themes such as austerity, trends in wealth and welfare, poverty, household savings and consumption trends as playing a significant part in a more equal Wales for the future.

1.4.7 The Hub participates in the PSB Co-ordinator Network, which is co-ordinated by Welsh Government and which (explain role on Network). To date, the Hub Team have attended meetings to raise awareness of work streams and to seek PSB co-ordinators’ advice on the type and nature of support required for well-being plans. Co-ordinators identified the need for short, tailored, visual information on topics such as how the environment impacts on health and well-being; the Hub team is now taking forward.

1.4.8 The Hub has also used the PSB Co-ordinators’ e-bulletin to alert co-ordinators to useful reports like:

o ‘Making a difference: investing in sustainable health and well-being for the people of Wales’ highlights the need to combine ‘investment in prevention’ with steps to address the economic, social and environmental determinants of health, framed by the principles of the WFG Act and prudent health care.

o Adverse Childhood Experiences research - a series of publications linking adverse childhood experiences (traumatic experiences that occur before the age of 18) with health-harming and antisocial behaviours, mental well-being and chronic diseases and health service use.

These resources can be used by public bodies and public Services boards to identify evidence-based action to help inform their response to the Act.

1.4.9 Public Health Wales is taking a proactive response to the recommendations contained within The Future Generations Commissioner report, ‘Well-being in Wales: Planning today for a better tomorrow’, on the learning from the local well-being assessments of each PSB. The Health and Sustainability Hub is in the process of identifying approaches for a public health system response to the Commissioner’s recommendations– with ideas for actions and opportunities to support PSBs at a national and local level.

1.4.10 Public Health Wales has long advocated Health Impact Assessment as a tool to support sustainable development; helping to ensure that both the short and long term impacts of policies, plans and projects are taken into consideration. The Wales Health Impact Assessment Support Unit, which is part of Public Health Wales, is dedicated to helping policy makers and practitioners develop and implement HIA in Wales. Since the introduction of the WFG Act the Unit has been supporting and development the role of well-being impact assessments in demonstrating that the public bodies and public services boards (among others) take the well-being goals into consideration.

1.4.11 Finally, Public Health Wales and the Health and Sustainability Hub are working on a new tool which will help to embed sustainable development and new ways of working. The intention is to pilot the tool in several settings including with statutory partners on the Public Services Board. The results (both positive and negative) will be used to refine and develop thinking around embedding sustainable development across public services.

1.5 References

1. Welsh Government. Tackling poverty action plan: 2012-2016. Cardiff: Welsh Government; 2012.

2. Mani A, Mullainathan S, Shafir E, Zhao J. Poverty Impedes Cognitive Function. Science. [Online] 2013;341(6149): 976–980. Available from: doi:10.1126/science.1238041 [Accessed: 5th December 2017]

3. Welsh Government. Rebalancing healthcare: Working in partnership to reduce social inequity: Chief Medical Officer for Wales Annual Report 2015-16. [Online] Welsh Government. Report number: WG28727, 2016. Available from: http://gov.wales/docs/dhss/publications/161110cmoreport16en.pdf [Accessed: 12th May 2017]