National Assembly for Wales / Cynulliad Cenedlaethol Cymru
 Health and Social Care Committee / Y Pwyllgor Iechyd a Gofal Cymdeithasol
 Public Health (Wales) Bill / Bil Iechyd y Cyhoedd (Cymru)
 Evidence from Royal College of Physicians – PHB 25 / Tystiolaeth gan goleg Brenhinol y Meddygon – PHB 25

Public health (Wales) bill 
 RCP (Wales) consultation response
 About us 
 The Royal College of Physicians (RCP) plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in Wales and across the world with education, training and support throughout their careers. As an independent body representing more than 29,000 fellows and members worldwide, including 800 in Wales, we advise and work with government, the public, patients and other professions to improve health and healthcare.
 Amdanom ni
 Mae Coleg Brenhinol y Meddygon yn arwain y ffordd o ran darparu gofal o ansawdd uchel i gleifion drwy osod safonau ar gyfer arferion meddygol a hybu rhagoriaeth glinigol. Rydym yn darparu addysg, hyfforddiant a chefnogaeth i feddygon yng Nghymru a ledled y byd drwy gydol eu gyrfa. Fel corff annibynnol sy’n cynrychioli mwy na 29,000 o gymrodorion ac aelodau ym mhedwar ban byd, gan gynnwys 800 yng Nghymu, rydym yn cynghori ac yn gweithio gyda’r llywodraeth, y cyhoedd, cleifion, a gweithwyr proffesiynol eraill i wella iechyd a gofal iechyd.
 For more information, please contact: 
 Beverlea Frowen
 Senior policy adviser for Wales (interim)


Royal College of Physicians (Wales)

Regus House - Tŷ Regus, Falcon Drive

Cardiff - Caerdydd CF10 4RU



Catherine Hunt


Health and Social Care Committee

National Assembly for  Wales

Pierhead Buildings

Cardiff Bay


From the RCP vice president for Wales

O’r is-lywydd yr RCP dros Gymru

Dr Alan Rees MD FRCP





From the RCP registrar

O’r cofrestrydd yr RCP

Dr Andrew Goddard FRCP



25 August 2015



Dear colleague,




Thank you for the opportunity to give written and oral evidence on the Welsh Government’s consultation on the Public Health (Wales) Bill.


Our Response


RCP agrees that


·         the public health bill should be an enabling framework  for new and future public health legislation 

·         legislation should be proportionate , evidence based  and is essential in certain circumstances

·         there should be a tobacco retail register in Wales

·         there should be a ban on the sale of e-cigarettes to people aged under 18

·         smoking cigarettes should be banned in hospital grounds and children playgrounds.


RCP does not agree that


·         there should be outright ban on e-cigarettes in public places as this is counter -productive and does not reflect the evidence base upon which government should seek to make legislation


RCP urges the government to


·         maintain the public health focus  and health for all in policies

·         extend existing regulations  for food standards

·         reaffirm the necessity for the NHS to implement fully the All Wales Obesity Pathway

·         establish a National Forum with cross governmental leadership to tackle Obesity.

·         legislate as soon as possible to minimise the harm of excessive alcohol consumption




RCP believes strongly that this public health bill should be substantial and act as the enabling frameworkwhich will galvanise and support the Welsh Government and other bodies to address emerging public health issues proactively as they arise and also act as the ‘coat hanger’ for future legislation and regulations. 


RCP believes that the Bill should

·         set out clearly the direction, ambition and framework for public health policy in Wales including defining the unique role of Welsh Government ,its immediate legislative competencies and those available to Wales for the future

·         drive and support targeted, evidence based change to the health and wellbeing of Welsh residents and importantly, as a priority introduce legislation proven to reduce  inequalities

·         become a crucial and separate component of the legislative armoury available to Welsh Government and by doing so, mitigate the potential for the Well-being of Future Generations (Wales) Act  2015 and the requirement on public bodies to produce local well-being plans to be the only vehicle for tackling public health challenges facing Wales

·         enact legislation but its application should be proportionate and always reflect a robust evidence base.


The Health Minister when providing recent evidence to the Health and Social Care Committee in June, 2015 referred to the constraints and the limitations of the powers available in Wales to act immediately. We acknowledge this position but are frustrated that this prevents Wales taking a wider and more immediate proactive approach to mitigate urgent public health challenges such as the obesity epidemic and reducing harm from the increasing numbers of people drinking too much alcohol.    We note that the Minister stated that


‘there are real constraints on us, and those constraints are particular in the field of obesity’


RCP will continue to lend its support by drawing upon its extensive membership and knowledge, to assist the Welsh Government to influence non devolved policy at the Westminster Government and also to support the Welsh Government secure additional devolved powers for Wales to implement legislation that reflects RCP policy and aspirations.


Our response


Part two: Tobacco and nicotine products


Over the past decade the RCP has powerfully advocated in favour of harm reduction for people addicted to tobacco smoking. The RCP recognises that electronic cigarettes and other novel nicotine devices can provide an effective, affordable, and readily available retail alternative to smoking tobacco. According to the recent independent evidence review of e-cigarettes by Public Health England, published in August 2015, e-cigarettes have the potential to significantly reduce levels of smoking and are 95% less harmful than smoking tobacco. This latest review provides sound evidence to support our view that smoking e-cigarettes is a valuable and effective tool to support people to give up smoking and that is does not provide a pathway for people to start smoking cigarettes.





The RCP does not support a comprehensive ban on the use of e-cigarettes in enclosed and substantially enclosed public places. The recent report published by Public Health England clearly demonstrates that smoking e-cigarettes has become a popular method to quit smoking tobacco. There is no evidence that smoking e-cigarettes in enclosed spaces poses a significant risk to other people from inhalation of its vapour. We also note the recent announcement that the Scottish Government has withdrawn a similar intention acknowledging that there are health benefits to smokers from using e-cigarettes. We feel that an outright ban on nicotine-containing devices (e-cigarettes) in public places is unwise, counter -productive and does not reflect the evidence base upon which government should seek to introduce new legislation. It will not help to achieve the ambitious Welsh Government target to reduce smoking rates to 16% by 2020, however it is vitally important that the effects of smoking  e-cigarettes in public places should continue to be monitored.


We strongly endorse the importance of regulation for e-cigarettes to ensure their safety and to put in place appropriate controls on their sale and marketing. We note the requirement for Wales to comply with the EU Tobacco Products Directive which comes into effect in March 2016. The RCP is not aware of any evidence that shows electronic cigarettes normalise tobacco smoking in indoor public places, although it will be important to safeguard  the uptake of e-cigarettes through restrictions on advertising and marketing, and other measures to ensure that e-cigarettes are not promoted as a fashion item, particularly to children .


If a ban on the use of e-cigarettes in enclosed and substantially enclosed public places were to be implemented in Wales, we would support an exemption for those living in prison. Smoking prevalence in prisons remains at a level significantly higher than the general population, and this puts prisoners and staff at risk from the harm caused by smoke inhalation. It is crucial that prisoners are given help and support in quitting, which could include the use of e-cigarettes in a controlled way.


The RCP strongly supports a ban on smoking tobacco in the grounds of hospitals and children play areas.The position of voluntary prohibition creates uncertainty, confusion and needs legislation to ensure that people are not subject to the harmful effects of tobacco based products.  Starting with public places where children may be present, healthcare facilities, leisure centres, parks is a sensible starting point. However, debate is needed on how far this restriction should extend. RCP notes the intention of some local authorities in England for example, Brighton and Hove Council, to ban smoking on its beaches from 2016.



Creating a national register of retailers and nicotine products


The RCP welcomes the proposal for a retail register which is in line with the Tobacco Control Action Plan. The introduction of a retail register in Scotland has been an effective way of monitoring availability and trends in availability and we would therefore support the introduction of a similar scheme in Wales. We also believe that a retail register would help local authorities to tackle the problem of under-age sales and assist in the enforcement of the display ban. Smoking is also increasingly concentrated in less affluent parts of Wales where many may purchase smuggled or fake tobacco products.  A register will mitigate the effects of this practice on legitimate small business. Any measure that helps to reduce the prospect of under-age sales is strongly welcomed.








The RCP supports the regulation of electronic cigarettes and other novel nicotine products as medicinesand it is important to note that in the event of the regulation of e-cigarettes as medicines by the UK Medicines and Healthcare Products Regulatory Agency (MHRA), it would be inappropriate to prevent patients from using prescribed medicines indoors


Prohibiting the handing over of tobacco or nicotine products under the age of 18


We welcome the proposed ban on the sale of e-cigarettes to people under 18, and on the proxy purchasing of e-cigarettes for those under 18. We would also support measures to prevent marketing to children and non-smokers, and the regulation of these products to guarantee quality standards and protect consumers. The proposal to make it an offence to deliver tobacco products to a person who is under the legal age of sale for tobacco products would be in line with other measures, such as the vending machine ban, point of sale display bans and the introduction of a retail register, to limit as far as possible the access of young people to tobacco products.


The RCP supports the proposal to use restricted premise orders I (RSOs) implemented via enforcement officers of local authorities in Wales as a further deterrent to reduce the under-age sale of tobacco based products.


Other comments


The narrow focus of this particular consultation is under stood and we welcomed the recent announcement by the Welsh Government to consult on a proposal to set a minimum price of 50p per unit of alcohol. However, the RCP wants to take this opportunity to reaffirm its concern regarding the following:


Maintaining the public health focus and health for all in policies


·         In a time of austerity and immediate service pressures the level of investment in public health and action to implement public health policies slips down the agenda. The scale and scope of the ‘preventable public health challenge’ continues to rise at an alarming rate. A continued focus and strong national leadership is needed to stem even greater pressure on resources.


·         The Public Health (Wales) Bill should contain a commitment to progressing health in all policies including a provision in the Bill to specify at a later date, a statutory responsibility to complete a health impact assessment for specific local and national plans. If this became a reality, including government policies, it would raise the profile of public health in society; help to increase awareness and knowledge of important public health issues and concerns across government departments and in all sectors. RCP will follow with interest, the development of the National Well-being Indicators in 2016 and the effectiveness of the proposed local well-being plans of public bodies and hope that these will add impetus to tackling some of our persistent and epidemic challenges clinicians encounter on a regular basis.

Food standards, poor nutrition and obesity


·         RCP is disappointed that the regulation of food standards in settings such as pre-school and care homes are not included within the Public Health (Wales) Bill. Food standards make an important impact on people’s health.

·         The risk of many chronic conditions, in particular coronary heart disease, obesity, diabetes and some cancers, is increased by poor diet and diet-related disease has been estimated to cost the NHS around £6 billion a year. The cost of obesity alone has been predicted to reach £49.9 billion per year by 2050 by the Foresight report.26 Wales faces some of the biggest challenges in the UK, with the Child Measurement Programme reporting prevalence of overweight or obese children to be 26% in reception year.27

·         Maintaining food standards, particularly in health settings such as hospitals which seek to keep people well, can influence the public’s perception of foods that are considered acceptable and healthy. The public sector provides food for some of the poorest and most vulnerable people living in Wales.  Catering Standards for Food and Fluid Provision for Hospital Inpatients, and the All Wales Hospital Menu Framework standards ensure patients receive adequate nutrition to assist with their recovery whilst in hospital, but a lot more could be achieved if we ensure that healthy and balanced meals and food are offered in staff restaurants (which may also include staff, patients and visitors). Mandated criteria for the provision of only healthier retail items in hospital restaurants and outlets would help hospitals in Wales to fulfil their responsibility for improving the health of the population they serve.

·         The extension of the Welsh Government’s Health Promoting Hospital Vending Directive into other public sector settings, such as Local Authority premises including leisure centres and community centres, would give added impetus to the cultural change needed regarding healthy and un-healthy food.


·         Health and Social Care Committee recommendations of 2014 and the implementation of the governments’ All Wales Obesity Pathway appear to be ignored, stalled or have secured limited prominence in strategic documents and delivery plans of Local Health Boards. 


·         The recently announced Strategic Plan for Public Health Wales 2015-2018 referred to action over the next three years to prevent obesity in children (0-7yrs) however it did not identify any action for adults or older children. Welsh Health Survey data from 2009/12 shows that 28 per cent of adults in the most deprived areas of Wales were obese compared to 17 per cent in the least deprived areas. For overweight and obesity combined, these figures were 61 per cent in the most deprived areas and 53 per cent in the least deprived. Obesity significantly increases the risks of diseases, such as diabetes, heart disease, cancer and stroke. A holistic approach to tackling the obesity epidemic is needed that recognises children within a family context and reduces the rising numbers of adults with obesity.



·         The potential for a cross government lead and a national group to oversee joined up action on obesity is an example of how government can demonstrate leadership, whilst facilitating strategic engagement from a wide range of stakeholders who collectively can marshal significant resources and achieve considerable impact on solving shared problems. RCP would commit fully to, and support such a forum.


Minimising the harm of excessive alcohol consumption


·         Opportunities to restrict the advertising of alcohol and the cross marketing of alcohol in retail outlets should be taken so that Wales can adopt where possible similar legislative practices as in Scotland.

·         We strongly welcome the consultation on the Draft Public Health (Minimum Price for Alcohol) Bill.



Finally, RCP is pleased to accept an invitation to give oral evidence and discuss our views in more detail on 17 September 2015.    Dr David Price, Regional Advisor for the RCP Wales and Beverlea Frowen will be attending.






With best wishes,




Dr Alan Rees                                                      Dr Andrew Goddard      

RCP vice president for Wales                      RCP registrar                     

Is-lywydd yr RCP dros Gymru                     Cofrestrydd yr RCP