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 the Older People’s Commissioner for Wales – PHB 32 / Tystiolaeth gan Gomisiynydd Pobl Hŷn Cymru – PHB 32




Response from the Older People’s Commissioner for Wales

to the

National Assembly for Wales consultation on the Public Health (Wales) Bill


September 2015



For more information regarding this response please contact:

Older People’s Commissioner for Wales,

Cambrian Buildings,

Mount Stuart Square,

Cardiff, CF10 5FL


About the Commissioner


The Older People’s Commissioner for Wales is an independent voice and champion for older people across Wales, standing up and speaking out on their behalf. She works to ensure that those who are vulnerable and at risk are kept safe and ensures that all older people have a voice that is heard, that they have choice and control, that they don’t feel isolated or discriminated against and that they receive the support and services they need. The Commissioner's work is driven by what older people say matters most to them and their voices are at the heart of all that she does. The Commissioner works to make Wales a good place to grow older - not just for some but for everyone.


The Older People’s Commissioner:

·        Promotes awareness of the rights and interests of older people in Wales.

·        Challenges discrimination against older people in Wales.

·        Encourages best practice in the treatment of older people in Wales.

·        Reviews the law affecting the interests of older people in Wales.












National Assembly for Wales consultation on the Public Health (Wales) Bill


1.   As the Older People’s Commissioner for Wales I welcome the opportunity to respond to the National Assembly for Wales’ Health and Social Care Committee consultation on the Public Health (Wales) Bill[1].


2.   There are almost 800,000 people aged 60 and over in Wales, over a quarter of the population, and, in the next twenty years, this is expected to exceed one million people. The fact that Wales is a nation of older people should be seen as something positive.


3.   Whilst the Bill does include some proposals that should help maintain the health and wellbeing of older people, I believe that the Bill lacks ambition and does not address the real public health issues that matter to older people across Wales.


4.   A more proactive and ambitious Bill is required to promote the benefits of a healthy lifestyle in all age groups. The Bill must drive forward improvements in service provision and address the public health challenges on Wales’ high streets that have a detrimental impact on older people’s health and wellbeing. These challenges include, as examples, drinking establishments (a fifth of people over 65 years old are drinking unsafe amounts of alcohol at the UK level[2]), bookmakers (gambling participation amongst people 55 years and older remains a concern[3]), payday loan shops (the growth of such providers is contributing to rising debt amongst older people[4]), and fast-food outlets (on the UK level, 32% of women aged 65 years and older are classed as overweight, with 54% of men in the same age group also classed as overweight[5]).


5.   Older people are vital assets, currently worth over £1bn to the Welsh economy annually[6]. The Public Health Bill has a crucial role to play in establishing a ‘virtuous circle’; maintaining the independence of older people, ensuring that they can continue to contribute to society, local and national economies, and reducing dependence on health and social care services already under significant pressures. The Bill should promote a preventative, outcomes-focused model that helps unlock the huge potential of older people to communities and economies across Wales.


6.   The Bill should complement and drive forward the Strategy for Older People 2013-2023[7] and also dovetail with the two legislative drivers that should help improve the lives of older people across Wales, namely the Social Services and Wellbeing (Wales) Act 2014[8], and the Wellbeing of Future Generations (WFG) (Wales) Act 2015[9].


7.   It should also contribute towards my Framework for Action 2013-17 priorities, particularly ensuring that people’s health and wellbeing is considered across all policies and portfolios (‘Embedding the wellbeing of older people at the heart of public services’), work towards a preventative approach that integrates health and social care services (‘Driving up the quality of, and availability and access to, health and social care’), and recognising that public toilets and other non-statutory services are essential community health assets (‘Protecting and improving community services, facilities and infrastructure’)[10]


Provision of Toilets


8.   The proposal for Local Authorities to prepare and publish a local toilets strategy is welcomed, however it does not go far enough and falls short of obligating Local Authorities to provide and maintain public toilets. Older people rarely call for strategies and instead require firm commitments and actions to ensure that they can continue with their daily lives and remain connected with their communities through the provision of public toilets and other non-statutory services. Older people in Wales have the right to expect access to open, clean and accessible public toilets.


9.   As I have consistently emphasised and highlighted in my report on ‘The Importance and Impact of Community Services within Wales’[11], public toilets and other community services are vital assets and are absolutely essential in maintaining the health, independence and wellbeing of older people.


10.               Good public toilet provision is a public health necessity. Closing public toilets affects physical health (older people are more likely to suffer from bladder or bowel incontinence), mental health (the fear of being unable to access toilets can lead to isolation and depression), and environmental health (the risk of infection from street fouling increases with the closure of public toilet facilities). Closing down or reducing access to public toilets is damaging to public health and has a detrimental effect on the economy, with older people, including local residents, visitors and tourists, less likely to visit places.


11.               As the Explanatory Memorandum acknowledges, poor public toilet provision is known to have particular negative impacts on older people, and often disproportionate impacts. Many older people will not leave their homes without the assurance of being able to access a public toilet in their village, town or city when the need arises[12]. The closure of public toilets across Wales has had a huge impact on the physical and mental health of older people. Almost 20% of public toilets managed by Local Authorities closed between 2004 and 2013, leading to older people becoming more susceptible to loneliness and social isolation, and requiring costly packages of health and social care[13].


12.               The proposal for public toilets to include changing facilities for babies and changing places for disabled persons is welcomed, but could go much further. Public toilets must be clean, safe and accessible places for older people and others, with handrails, wheelchair ramps and visual and hearing aids for those with mobility issues and sensory loss.


13.                The proposal for Local Authorities to consult with local stakeholders is welcomed, and, as emphasised in my Best Practice Guidance for Engagement and Consultation[14], I fully expect that older people across Wales are given every opportunity to voice their needs and concerns. As regular users of community services, older people are ‘experts by experience’ and are well placed to gauge the effectiveness of local public toilet provision.


14.               The requirement for Local Authorities to assess local need for public toilets must be supported by adequate resources. I am fully aware of the stark financial challenges facing Local Authorities and support all efforts to provide them with the resources required to provide public toilets. I am not convinced that the former Community Toilet Grant scheme, whereby the public are able to use toilets in local businesses, is a model that can adequately replace public toilet provision.


15.               Older people have told me that they often feel uneasy or embarrassed about using Community Toilet Schemes, and instead require dependable and accessible public toilets. Furthermore, the Welsh Senate of Older People’s ‘P is for People’ campaign found that 85% of respondents would be prepared to pay a small amount in order to use a public toilet[15].


16.               As part of the Ageing Well in Wales Programme[16], all Local Authorities have signed the Dublin Declaration, a commitment to establish age-friendly communities in their area. Adequate public toilet provision plays a key role in establishing such communities and the Bill must go further in ensuring that older people and others can access public toilets across Wales.


General remarks


17.               Beyond public toilet provision, there is very little reference to older people in the Bill and Explanatory Memorandum. The Bill is a missed opportunity in terms of addressing the range of public health issues that matter to older people. These include the following:


-      Loneliness and Isolation: A serious public health issue that is affecting an increasing number of older people across Wales, and exacerbated by the closure of ‘lifeline’ community services such as public buses, public toilets, libraries, day centres, meals on wheels and befriending schemes. Loneliness can have a serious impact on a person’s physical and mental health and wellbeing, and has an effect on mortality that is similar in size to smoking 15 cigarettes a day[17].


It is estimated that more than 75% of women and a third of men over the age of 65 live alone. Without the means to leave their homes, or with fewer visits from community workers and service providers, an increasing number of older people will feel lonely and isolated, resulting in damaging effects to their mental health and increased exposure to alcohol misuse. These ‘silent killers’ need to be addressed as a matter of urgency, and for this reason Loneliness and Isolation is a priority theme within the Ageing Well in Wales Programme[18]. The Bill should be complementing the Programme’s aims and outcomes, unfortunately the urgent need to tackle loneliness and social isolation is a glaring omission in the Bill. 


-      Nutritional value of food in care homes: As I mentioned in my response to the consultation on proposals for a Public Health Bill[19], it is crucial for older people living in care homes that they are provided with a nutritional, balanced meal and that care home staff are aware of the benefits that good nutrition brings to older people. Malnutrition is estimated to affect between 16-29% of older people living in care homes across Wales and one in three older people are affected by malnutrition upon entry into residential care homes.


As my Review into the quality of life and care of older people living in care homes in Wales states[20], action to ensure that the dietary needs of individuals are met and that malnutrition is prevented wherever possible is essential to maintain the health, wellbeing and quality of life of older people living in care homes. It is regrettable that the White Paper proposal to introduce nutritional or food based standards in care homes settings is not taken forward in the Bill.


-      Building community assets for health: I welcomed this approach in the White Paper as it recognises the importance of local health care services in maintaining the health, independence and wellbeing of older people and others. Whilst the Bill does recognise the importance of accessing local pharmaceutical services and public toilets, it does not address improved access to effective integrated care and support and person centred primary care services, as referred to in the White Paper.


A preventative approach is required to ensure that older people stay safe, independent and healthy, and that healthcare support is timely, accessible and effective when they require it. The Bill does not address the barriers that older people often face in accessing support, such as GP appointment booking systems, nor the need to improve integration between GP surgeries, dental practices and pharmacies in order to reduce avoidable hospital admissions and the need for costly packages of health and social care.


-      Obesity and physical inactivity: As I highlighted in my supplementary response on the benefits of physical activity[21], the maintenance of a healthy lifestyle and keeping active is a significant preventative measure in the onset of a number of health conditions. Evidence suggests that physical activity levels decline rapidly with increasing age; people over 65 years old in Wales attain less than half the physical activity of 16-34 year olds. Despite the worrying levels of physical inactivity amongst older people, the Bill does not address the needs of older people and improve the awareness of older people of physical activity opportunities available to them e.g. free swimming classes, outdoor activities, or tailor-made exercise classes in community settings or residential care homes.


It is regrettable that the Bill does not promote the benefits of physical activity and the particular needs of older people. Such an approach, complemented by a proactive approach on nutritional standards and educating citizens on healthy eating, would be effective in addressing Wales’ obesity crisis, with 58% of people aged 16 years and older classified as overweight or obese[22]. Obesity amongst older people is a growing concern, with one in four older people now considered obese in the UK[23].


-      Tobacco and Alcohol: Much of the debate around the new Bill has centred on the banning of e-cigarettes in enclosed public spaces. The Bill however could go further in tackling tobacco and alcohol dependence in Wales, and educating people about the dangers of misuse and the benefits of a healthy lifestyle. Such an approach would be helpful in addressing dependence amongst different age groups, including older people.


Around 20% of adults in Wales are smokers, and more needs to be done to address smoking amongst older people. Quitting smoking in later life can lead to significant health benefits and increase longevity[24].


Since the publication of the Public Health Bill, the subsequent Public Health (Minimum Price for Alcohol) (Wales) Bill may be useful in deterring some individuals from alcohol misuse but will do little to address harmful alcohol drinking amongst older people in ‘middle classes’, with minimum pricing unlikely to deter those with steady incomes and live in relative affluence[25]. Alcohol misuse in this group is a growing concern as demonstrated by a recent study in England[26].


As the White Paper indicated, the Welsh Health Survey between 2008 and 2012 showed an increase in older people drinking above the daily guidelines[27]. With an ageing population, alcohol misuse amongst older people is a growing concern, with an estimated 1.4m older people drinking above guidelines at the UK level[28][29].


I am pleased that the National Assembly’s Health and Social Care Committee report on ‘Alcohol and substance misuse’, published after the publication of the aforementioned Bills, does address older people and that more awareness raising and training around the issues facing older people is needed, particularly as alcohol and substance misuse amongst older people ‘often goes undetected’ due to ‘trigger events’ such as retirement or bereavement’[30].


The Public Health Bill should go further in issuing guidance to improve identification and access to substance misuse services for older people, as referred to in the White Paper. Clarification on how the Public Health (Minimum Price for Alcohol) (Wales) Bill will complement and link with the broader Public Health Bill is also needed.




18.               Although the public toilets proposal is a step in the right direction, and the importance of assessing local need for pharmaceutical services is addressed, I believe that the Bill lacks ambition and is a missed opportunity to tackle the real public health issues that affect older people across Wales; it falls short of what is needed for older people. With such a broad and diverse set of issues ranging from tobacco, intimate piercing and public toilets, I am very concerned that the Bill lacks a coherent vision, and omits many of the positive proposals included in the White Paper; there is no holistic approach.


19.               Wales’ health, social care and public services cannot afford not to maintain the independence and wellbeing of older people, and I am concerned the Bill will not add value in enhancing Welsh public health, reducing health inequalities, contributing to the Strategy for Older People and the ‘A healthier Wales’ national wellbeing goal within the WFG Act. In its current form Wales will miss an opportunity to improve the quality of life of older people across Wales.