Introduction

1. The Welsh NHS Confederation, on behalf of its members, welcomes the opportunity to contribute to the Communities, Equality and Local Government Committee inquiry into poverty in Wales: Strand 1 “Poverty and inequality”.

2. By representing the seven Health Boards and three NHS Trusts in Wales, the Welsh NHS Confederation brings together the full range of organisations that make up the modern NHS in Wales. Our aim is to reflect the different perspectives as well as the common views of the organisations we represent.

3. The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work. Members’ involvement underpins all our various activities and we are pleased to have all Local Health Boards and NHS Trusts in Wales as our members.

4. The Welsh NHS Confederation and its members are committed to working with the Welsh Government and its partners to ensure there is a strong NHS which delivers high quality services to the people of Wales.

5. In response to the inquiry we are not providing specific answers to all the questions posed but are providing comments about how poverty, particularly destitution and extreme poverty, can impact on people’s health. While Strand 1 of the inquiry is considering “poverty and inequality”, and the Committee will be seeking views in the future on the impact of welfare reform on poverty in Wales as part of its Strand 2 work, these two areas cannot be separated in relation to the impact they have, and are having, on people’s health in Wales. Furthermore, we recommend that the Welsh Government and National Assembly provide greater consideration to the impact poverty has on the health of the population when developing future Acts, including the Public Health (Wales) Bill and the Well-being of Future Generations (Wales) Bill.

Terms of Reference

ii) the impacts of poverty, particularly destitution and extreme poverty, on different groups of people;

6. The impact of poverty on health is significant. The Marmot report[i] found that people living in the poorest areas of England and Wales will, on average, die seven years earlier than people living in the richest areas. The average difference in disability-free life expectancy is even worse with 17 years between the richest and poorest neighbourhoods. Evidence shows that people living in deprived areas develop multiple conditions earlier than people in more affluent areas and many people of working age have multiple conditions.[ii] On average, between 2009-2010 and 2011-2012, almost a quarter of people in Wales (23%) were in low income households - higher than in both England and Scotland.[iii] Many of these factors are interlinked, and a person’s overall well-being will affect their ability to adopt healthy behaviours.[iv]

7. In our recently published briefing, ‘The health impacts of welfare reform’[v], attached with our submission, the Welsh NHS Confederation highlighted the likely impact that welfare reform will have on people’s health and wellbeing in Wales and how this cannot be underestimated.

8. As our briefing highlights, there is clear evidence that suggests that due to poverty, and as a result of the current welfare benefit changes, there will be short term and long term health effects. The consistent predictions are:

a. increased cardiovascular and respiratory illness;

b. increases in obesity-related illnesses;

c. worse mental health and general wellbeing;

d. increases in avoidable winter mortality;

e. increased suicide and attempted suicide;

f. increased homicides and domestic violence;

g. increased mental health problems including depression and lower levels of wellbeing;

h. increased rates of tuberculosis and human immunodeficiency virus (HIV);

i. increased substance misuse and associated alcohol- and drug-related harms;

j. increased unprotected sex and associated rises in sexually transmitted infections;

k. increased health inequalities;

The mechanisms which have been proposed to lead to these health outcomes include:

l. decreased real incomes;

m. increased income inequalities;

n. increased fuel poverty;

o. increased food poverty (and a consequent shift from quality foodstuffs to calorific quantity);

p. increased stigmatisation;

q. decreased housing security; and

r. psychological impacts of unemployment and job loss.

9. These predictions are based on what is already known about the impact of these mechanisms on health and health inequalities. They are also based on the assumption that the current welfare reforms will have the effect of creating the conditions in which significant proportions of the population will be affected by these mechanisms. Overall, however, it is clear that there is still uncertainty around the range of health impacts, their magnitude and their timing.

10. The Scottish Public Health Observatory[vi] has recently reported that “there is general consensus that income inequalities do impact on health inequalities”, and this has been evidenced by the Citizens Advice Cymru report ‘One day at a time’[vii]. The report found that two out of five participants who participated in the report said they believed their physical health has suffered as a result of the welfare reform changes, which was linked to the increased level of stress they are experiencing. In addition, nearly all of those questioned in the report felt their mental health had been negatively affected by the recent changes, saying they had suffered from increased stress, anxiety and depression.

11. The Welsh NHS Confederation recommends that when considering tackling poverty, and the impact welfare reform will have on people in Wales, it is now the time for all sectors in Wales to work together in an integrated and holistic way to minimise the health and wellbeing implications for people in Wales. As the Welsh NHS Confederation ‘From Rhetoric to Reality – NHS Wales in 10 years’ time’[viii] discussion paper evidences, the NHS, and all sectors in Wales, must work in an integrated and holistic way because: “In public services, we are only as strong as our weakest link”. Through supporting each other we will help to ensure positive outcomes for people.

12. Providing holistic and integrated support to people is supported by Welsh Government policy, including the ‘Tackling Poverty Action Plan 2012-2016’. The Plan describes initiatives that place multidisciplinary teams around families to provide a holistic approach to addressing the various factors relating to poverty. The plan reflects the cross sector approach that is needed to tackle poverty effectively.

iii) how legislation, policy and budgets targeted at tackling poverty and reducing inequality are co-ordinated and prioritised across the Welsh Government.

Public Health White Paper and Well-being of Future Generations Bill.

13. When consider how legislation and policy around tackling poverty is co-ordinated and prioritised across the Welsh Government, the Welsh NHS Confederation recommends that the Welsh Government considers tackling poverty within future legislation, including the Public Health White Paper and Well-being of Future Generations Bill, because poverty and deprivation are linked to many of the public health concerns and outcomes in Wales.

14. The Welsh NHS Confederation submitted a comprehensive response to the Public Health White Paper in June 2014, and to the recent National Assembly Environment and Sustainability Committee inquiry into the general principles of the Well-being of Future Generations (Wales) Bill. We have recommended within both responses that to improve public health, and improve people’s well-being, it is essential to tackle poverty.

a) Public Health White Paper

15. Within the Public Health Wales Bill we recommended that there needs to be a clear vision within the Bill around how poverty and deprivation is going to be tackled to maintain people’s health and well-being. We have highlighted the importance of working in an integrated and holistic way across Government departments and the public sector and how the importance of tackling poverty to improve people’s health cannot be underestimated. Poverty and deprivation are linked to many of the public health concerns and outcomes in Wales. Therefore it is vital that the Public Health Bill ensures that the Welsh Government is obliged to consider the impact of poverty on the health of the population.

16. The new Bill could provide an effective platform for reducing health inequalities in Wales. Lifestyle interventions currently have their place in reducing health inequalities, in improving environmental matters relevant to public health, and in creating supportive communities for changing the average behaviour of the population. The emphasis on making healthy choices is frequently over-ridden by more powerful social, economic, lucrative markets and environmental influences. The Public Health Bill must be used to foster the conditions that limit the obstacles to achieving health across the span of the population.

b) Well-being of Future Generations (Wales) Bill

17. In commenting on The Well-being of Future Generations (Wales) Bill, the Welsh NHS Confederation highlighted that the Bill is an important opportunity to address the complex long-term challenges we experience in Wales including health inequalities, tackling poverty, demographic changes and public engagement.

18. While tackling poverty is implicit in the majority of the “well-being goals” within the Bill, the Welsh NHS Confederation would recommend that the alleviation of poverty is included more explicitly within the Bill. Sustainable development is impossible if we do not address the inequities that exist within Wales and in how Wales relates to the rest of the world. It is vital that the Bill ensures that the Welsh Government is obliged to consider the impact poverty has on people’s well-being. The Bill needs to be more explicit in relation to how the Welsh Government and public bodies are going to ensure that poverty and financial inequality are tackled in Wales.

Conclusion

19. Poverty has a significant impact on people’s health and overall the Welsh Government Tackling Poverty Action Plan has been effective in providing cross sector and co-ordinated support to people living in poverty in Wales. However, the Welsh NHS Confederation recommends that it is important that when National Assembly legislation is developed, tackling poverty should always be considered and prioritised.