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 Age Cymru – PHB 42 / Tystiolaeth gan Age Cymru – PHB 42

Age Cymru logo (CMYK Coated)

Consultation Response


Public Health (Wales) Bill: Stage 1


August 2015


Age Cymru is the leading charity working to improve the lives of all older people in Wales. We believe older people should be able to lead healthy and fulfilled lives, have adequate income, access to high quality services and the opportunity to shape their own future. We seek to provide a strong voice for all older people in Wales and to raise awareness of the issues of importance to them.


We are pleased to respond to the Health and Social Care Committee’s consultation on Stage 1 of the Public Health (Wales) Bill. In our response, we will focus in particular upon pharmacy services and public toilet provision.


Part 5: Pharmaceutical services


Do you believe the proposals in the Bill will achieve the aim of improving the planning and delivery of pharmaceutical services in Wales?


We believe there is scope for community pharmacies to make a greater contribution to health services in Wales in a way which will be of benefit to older people by ensuring services are delivered within communities and are easily accessible. Further work is also needed to raise the profile and awareness of services which are available from pharmacies, as people are often simply unaware of the services they can access at their local pharmacy.


What are your views on whether the proposals will encourage existing pharmacies to adapt and expand their services in response to local needs?


It is to be hoped that the use of pharmaceutical needs assessments by the Local Health Boards would encourage existing pharmacies to adapt and expand their services in response to the needs identified. However, the impact of the pharmaceutical needs assessments will need to be kept under review and, specifically, will need to consider whether the provisions of the Public Health (Wales) Bill are in fact encouraging existing pharmacies to respond in the intended manner.


Do you believe the proposals relating to pharmaceutical services in the Bill will contribute to improving public health in Wales?


The provisions of the Bill have the potential to improve public health in Wales through the extension of pharmaceutical services. In particular, Age Cymru would welcome the extension of services in the following areas: minor ailments schemes; management of chronic conditions; and hospital discharge.


Age Cymru believes that there is the potential for community pharmacies to deliver minor ailments schemes in a way which beneficially reduces pressure on GPs and improves access and choice for patients. A shift towards providing more identification and treatment of minor ailments in community pharmacies could reduce pressure on GP appointments and therefore improve access for patients with more severe health conditions. This will require greater commissioning of such services by local health boards, increased referral by GP surgeries so that they can better prioritise GP and nurse appointments, and improved public awareness of the services which can be provided by community pharmacies.


Statistics from Community Pharmacy Wales[1] indicate that an estimated 5 million GP consultations every year concern minor ailments. An independent review concluded that almost 40% of these consultations could have been effectively handled in a community pharmacy. Research has also indicated that if patients with minor ailments were seen by their pharmacist instead of their GP potentially £30 million could be saved by the NHS in Wales each year.[2]


Two-thirds of the population of Wales aged 65 or older report having at least one chronic condition while one-third have multiple chronic conditions.[3] The Auditor General’s report on the management of chronic conditions[4] concluded that too many patients with chronic conditions were treated in an unplanned way in acute hospitals, accounting for one in six of all emergency medical admissions.


Community pharmacies already play a significant role in supporting people living with chronic conditions through medicines management services combined with regular monitoring and support, but we believe that this could be done in a more consistent and comprehensive way.  Community pharmacies could be fully integrated into chronic conditions pathways providing easily accessible facilities for testing a range of morbidities, delivering flu vaccinations, supporting people living with diabetes, heart disease and respiratory conditions.


Over a long period of time Age Cymru has heard many examples of poor practice in relation to the discharge of older people from hospital. A frequent concern relates to older people being discharged without a suitable after-care package in place (including medication reviews), sometimes with an assumption that the family will provide support. A lack of support, including in medication management, can result in side-effects, deterioration of patient’s conditions and hospital re-admission.


As a result we would support a much greater role for community pharmacy in hospital discharge and after-care, and greater publicity around the role that a community pharmacist can play in providing regular medication reviews. In Wrexham, a community pharmacy-based pilot scheme involving medicines information exchange on patient discharge from hospital resulted in clinically significant interventions in 19% of patients.[5] There is also greater scope to be explored in the role of community pharmacy in the management of medication in care homes.


Part 6: Toilets for public use

What are your views on the proposal that each local authority in Wales will be under a duty to prepare and publish a local toilets strategy for its area?


Adequate public toilet provision is vital to enable older people to maintain their dignity and participate in community life. Despite the importance of these facilities, public toilets are disappearing from our communities at an alarming rate and we believe that assertive action is needed to halt this decline. To that end, we welcome the proposal to establish a duty for each local authority to prepare and public a local toilets strategy for its area. However, we remain concerned that creating a duty to develop a strategy will be insufficient to halt the decline in numbers of public toilets.


Do you believe that preparing a local toilet strategy will ultimately lead to improved provision of public toilets?


We recognise that the current proposal to place a duty on local authorities to develop a strategy for the provision of and access to toilets for public use in their area is a step in the right direction. We are acutely aware that all local authorities face difficult challenges when managing current and future budgets, and we are very concerned that Wales’ public toilets network is at real risk unless action is taken to protect them.


We therefore remain concerned that the duty to develop a toilet strategy will not lead to any improvements in the current level of provision as there is no guarantee that the development of a strategy will ensure that adequate numbers of accessible public toilets are made available.


Do you believe that provision in the Bill to ensure appropriate engagement with communities is sufficient to guarantee the views of local people are taken into account in the development of local toilet strategies?

We welcome the proposal for these strategies to be based on local community needs, consulted upon and reviewed on a regular basis.


Do you have any views on whether the Welsh Ministers’ ability to issue guidance on the development of strategies would lead to a more consistent approach across local authorities?


We welcome the prospect of Welsh Ministers being able to issue guidance on the development of strategies aimed at ensuring a more consistent approach to the provision of public toilets across the local authorities in Wales. It is not appropriate that the ability of older people to maintain their dignity and participate fully in community life through the provision of public toilet access be restricted as a consequence of living within the boundaries of a particular local authority.  


It is also vitally important that the implementation of these strategies is enforced and closely monitored by the Welsh Government to ensure that adequate numbers of accessible toilets for public use are provided across Wales.



What are your views on considering toilet facilities within settings in receipt of public funding when developing local strategies?


All appropriate mechanisms should be considered to ensure that older people have access to safe, accessible and well-maintained facilities.


Do you believe including changing facilities for babies and for disabled people within the term ‘toilets’ is sufficient to ensure that the needs of all groups are taken into account in the development of local toilet strategies?


We believe that these local strategies should work alongside standards to ensure that toilets for public use are in convenient locations, open, accessible and clean. Toilets, including changing facilities, must be provided where people need them, to ensure that older people across Wales are able to manage any increased dependency on toilets with dignity. This includes transport terminals, shopping centres and parks. Disabled access toilets should also be provided in all civic areas, to ensure that local authorities meet their statutory duty to ensure disabled people are able to use those areas with the same confidence and freedom as all other users.


Do you believe the proposals relating to toilet provision in the Bill will contribute to improving public health in Wales?


Age Cymru’s preferred position would be for the Welsh Government to impose a statutory duty on local authorities in Wales to provide adequate numbers of accessible public toilets across Wales. Public toilets play a vital role in ensuring that communities are accessible to people of all ages. They can be a lifeline for older people, providing them with freedom, independence and the confidence they need to lead fulfilling and active lives.


We welcome the extension of the Welsh Government funded Community Toilet Grant Scheme, which provides local authorities with grant funding to encourage local businesses to open their facilities to the public. However, we have concerns that sign-up to the Scheme varies considerably across Wales,[6] as demonstrated in the Explanatory Memorandum, and that the future funding for this Scheme will no longer be ring-fenced but will be part of the general Revenue Support Grant. We note from the Explanatory Memorandum that re-hypothecation of the funding was considered but ruled out due to potential impacts on other service areas. It is difficult to see how a duty to develop a strategy can deliver adequate access to safe, well-maintained and accessible public toilets without funding to underpin improvements in the current level of provision.


We believe that the Community Toilet Grant Scheme, together with the provision of toilet facilities for public use within public buildings, must be better publicised and promoted. There must be clear and visible branding and signage, if they are to form part of a co-ordinated sustainable solution to toilet provision alongside public toilets provided by the local authority.


Other comments

Are there any other comments you wish to make about specific sections of the Bill?


In our response to the Welsh Government’s White Paper consultation, Age Cymru welcomed the principle of ensuring the implementation of the principle of nutritional standards in care homes. We note the Welsh Government’s intention to proceed on this issue through the use of subordinate legislation. We urge the Health and Social Care Committee (or potentially its successor) to ensure that this commitment is met.


Care home residents should be provided with balanced meals and it is also vital that all residents have ready access to fluids, and support to consume them if required, to prevent malnutrition and dehydration.


In recent years the public health agenda has focused resources on tackling the obesity crisis with much less attention being paid to malnutrition. This is despite the economic burden of malnutrition in the UK being estimated to be around £7.3 billion a year - equivalent to obesity. Over half of these costs are being expended on people over the age of 65.[7]


It is important to stress that whilst work has been done to try to tackle malnutrition and dehydration in hospitals, unfortunately it still remains a problem in some wards, as demonstrated by the 2014 ‘Trusted to Care’ report which identified, among other serious areas of concern, failures in keeping older patients hydrated. Therefore further work is required in hospitals as well as care homes to improve nutrition and hydration.


Hydration standards are particularly welcomed as we often hear anecdotally in care homes (and in hospitals) that people do not have constant access to fluids, often if you miss the ‘tea trolley run’, you may not be offered a drink for hours.


A balanced diet is also clearly important for good health, but we note standards must be careful to avoid restricting individual preferences and right to choice over foods. People with dementia often experience a change in their taste preferences and flexibility must be incorporated to allow for this. It should also be considered whether such standards should be extended to cover domiciliary care in situations where a paid carer is the sole provider of main meals.

We hope these comments are useful and would be more than happy to provide further information if required.

[1] Community Pharmacy Wales Manifesto 2011: The best medicine for healthy lives in Wales, Community Pharmacy Wales, 2011

[2] The Bow Group: Delivering Enhanced Pharmacy Services in a Modern NHS, 2010

[3] The management of chronic conditions in Wales – an update, Wales Audit Office, 2014

[4] The management of chronic conditions by NHS Wales, Wales Audit Office, 2008

[5] Community Pharmacy Wales Manifesto 2011: The best medicine for healthy lives in Wales, Community Pharmacy Wales, 2011

[6] Welsh Senate of Older People (2014) P is for People. Campaigning for better public toilets in Wales. Report on findings of Campaign Working Group of the Welsh Senate of Older People. Spring 2014.

[7] Tackling malnutrition among older people in the community, Discussion paper from the Welsh Consumer Council, 2008