3 September 2014


Well-being of Future Generations (Wales) Bill


The response of Cardiff & Vale University Health Board to

the Inquiry by the National Assembly Environment and Sustainability Committee


1.    The Cardiff & Vale University Health Board (UHB) welcomes the establishment of the Well-being of Future Generations (Wales) Bill and its focus on well-being and sustainable development. We support the positioning of sustainable development as a central organising principle and it being placed on a statutory basis. The UHB is responsible for promoting the health and well-being of the population of Cardiff and the Vale of Glamorgan and views the implementation of this Bill, alongside the Public Health Bill, as contributing to improved health outcomes and reduced inequalities experienced by our citizens.


2.    We welcome the opportunity to contribute to the Environment and Sustainability Committee’s inquiry into the general principles of the Well-being of Future Generations (Wales) Bill and make the following comments.


3.    The Common Aim. We believe that an opportunity to prioritise population health has been missed by omitting to specify health in the Common Aim as one of the aspects of well-being alongside social, economic and environmental considerations. We recommend that an amendment to the Bill is considered to explicitly include health within the Common Aim. The following provides some evidence to support our recommendation:-


3.1 As a consequence of the Bill, public bodies will be expected to ‘improve the economic, social and environmental well-being of Wales in accordance with the sustainable development principle’. These factors influence and are influenced by, health. The Social Determinants of Health model (1), Figure 1, developed by Dahlgren & Whitehead illustrates how the various factors impact on the health of populations and similarly how population health at the core impacts on those factors in the outer layers.

Description: http://www.nnotts.nhs.uk/publichealth/phprofiles/PublicHealth/NNPHN/Profiles/Determinants/DETER1.jpg

Figure 1 Social Determinants of Health Model


3.2 Health 2020 (2) was agreed in 2012 by the World Health Organisation European Region and its 53 member states, one of which included the United Kingdom. Health 2020 is the European Health Policy Framework that supports action across government and society to significantly improve the health and well-being of populations, reduce health inequalities, strengthen public health and ensure sustainable people-centred health systems. This Framework provides support for placing health explicitly at the core of all national strategies to ensure cross government working; the UHB believes that the Framework offers evidence and support in implementing the Bill.


3.3 Numerous studies, including the Marmot Review (3), evidence the impact of social, economic and environmental inequalities on health; inequalities across these factors underpin the determinants of health and the range of interacting factors that shape health and well-being. Health is viewed as a fundamental element of well-being alongside economic, social and environmental considerations. The UHB concludes from the evidence that health requires explicit inclusion within the common aim. 


4.    Health in All Policies. The UHB has identified that an opportunity to embed a ‘health in all policies approach’ across the Well-being Goals and the Well-being Objectives of public bodies, Welsh Ministers and Public Service Boards has been missed. We are concerned that the major public health and health care service delivery challenges that we face may not be effectively addressed within the proposed legislative framework as outlined in the Future Generations Bill and suggest amendment to the Bill to ensure that a health in all policies approach is adopted. The following provides some evidence to support our recommendation:-


4.1 Health is often adversely affected by policies made in non-health sectors and there is support across Wales (4)  and the rest of Europe for the adoption of a health in all policies approach that focuses across the whole of government, civil society and local communities, business, global fora and international agencies (5) (6). Waste, transportation, housing, energy, commerce, education, the arts, leisure and  water, for example and as highlighted in the Social Determinants of Health model above, all impact on and play a role in, the health of the population. These services are organised and delivered by organisations that implement national policies and hold many of the major levers for public health, such as the use of local authority planning policy to address obesogenic environments, the use of transportation policy to improve walkability in neighbourhoods.  Explicitly placing improvement in health as a major criterion for successful delivery of national and local organisational policies will highlight progress already made by non-health sectors and contribute to reducing health inequities and inequalities.


4.2 Reviews by the Commission on Social Determinants of Health (7) and the Marmot Review Team (3) recommend focus in all policies to address health inequity; health in all policies is deemed to be one approach for addressing this.


5.    Health Impact Assessment. Health Impact Assessment maybe defined as ‘a combination of procedures, methods and tools by which a policy, programme or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population’ (8). It is a flexible and systematic process incorporating consideration of the economic, social and environmental determinants of health and well-being. Fairer Health Outcomes for All (4)recognised the importance of health impact assessment in supporting a health in all policies approach.  The UHB suggests that health impact assessment is recommended within the supporting guidance as a useful tool to support the taking forward of the health in all policies approach.


6.    Planning Cycles. The UHB supports the establishment of statutory Public Service Boards to enable stronger commissioning and planning discussions. We are already moving at pace to integrate services more effectively. We welcome the move to reform integrated community planning and simplify the system, removing the need to develop separate plans for aspects which can much more efficiently be addressed together.  We are concerned however that there will remain a tension between planning cycles given the focus on three-year planning within the NHS and different timeframes within national and local political cycles.  As far as possible, the relevant planning cycles should be aligned and a consistent approach to the relationship with the Bill requirements adopted within respective planning guidance to ensure coherence and co-ordination, and line of sight to sustainable development as a central organising principle.  The UHB request alignment of planning cycles and clarification in the guidance on the relationship between the new requirements and existing planning requirements for NHS and partner agencies.


7.     Conclusion. In summary, the UHB recommends that

·         The Bill be amended to incorporate health within the Common Aim

·         The Bill be amended to ensure that a health in all policies approach is adopted

·         The use of health impact assessment is encouraged as a useful tool within the supporting guidance

·         Clarification is provided in the supporting guidance on the relationship between the new requirements and existing planning requirements for NHS and partner agencies, and that the relevant planning cycles are aligned.


8.    The UHB is committed to supporting the successful implementation of the Well-being of Future Generations Bill and the Public Health Bill. Through these Bills there is a once in a generation opportunity to place public health at the centre of our public policy and practice.


9.    The UHB does not wish to present oral evidence.


Yours sincerely




Dr Sharon Hopkins                                                             Abigail Harris

Executive Director of                                                           Executive Director of Strategic

Public Health                                                                        & Service Planning



For further information, contact

Susan Toner susan.toner@wales.nhs.uk 02920 336204

Anne Wei anne.wei@wales.nhs.uk 02921 847730






1. M, Dahlgren G & Whitehead. Policies and strategies to promote social equity in health. [Online] 1991. [Cited: 26 August 2014.] http://whqlibdoc.who.int/euro/-1993/EUR_ICP_RPD414(2).pdf.

2. World Health Organisation. About Health 2020. World Health Organisation. [Online] WHO Regional Office for Europe. [Cited: 26 August 2014.] http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-policy-for-health-and-well-being/about-health-2020.

3. Marmot Review Team. Fair Society Healthy Livies. UCL Institute of Health Equity. [Online] 2008. [Cited: 26 August 2014.] http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review.

4. Welsh Assembly Government. Fairer Health Outcomes for All. Welsh Government. [Online] 2011. [Cited: 26 August 2014.] http://wales.gov.uk/docs/phhs/publications/110329working2en.pdf.

5. Ståhl T, Wismar M, Ollila E, Lahtinen E & Leppo K. Health in All Policies. Prospects and potentials. World Health Organisation Regional Office for Europe. [Online] 2006. [Cited: 26 August 2014.] http://www.euro.who.int/__data/assets/pdf_file/0003/109146/E89260.pdf?ua=1 .

6. Leppo K, Ollila E, Pena S, Wismar M and Cook S. Health in All Policies. Seizing opportunities, implementing policies. European Observatory on Health Systems adn Policies. [Online] 2013. [Cited: 26 August 2014.] http://www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf.

7. The Commission on the Social Determinants of Health. Closing the Gap in a Generation. Health equity through action on the social determinants of health. [Online] 2008. [Cited: 26 August 2014.] http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf?ua=1.

8. Wales Health Impact Assessment Support Unit. Health Impact Assessment. A Practical Guide. Wales Health Impact Assessment Support Unit. [Online] 2012. [Cited: 26 August 2014.] http://www.wales.nhs.uk/sites3/page.cfm?orgid=522&pid=63782.