PHB
04
Bil
Iechyd y Cyhoedd (Cymru)
Public
Health (Wales) Bill
Ymateb
gan: Iechyd Cyhoeddus Cymru
Response
from: Public Health Wales
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Public
Health Wales NHS Trust Submission to the
Health,
Social Care and Sport Committee
Call
for Evidence: Public Health (Wales) Bill
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Date:
28
November 2016
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Version:
1
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This
information should be read alongside the previous (updated)
submission ‘Public Health Wales NHS Trust, Response to the
Health and Social Care Committee Consultation on the Public Health
(Wales) Bill’, dated 4th September 2015 (Appendix
1).
Re-
introduction of the Public Health Bill, November 2016
1.
Public
Health Wales welcomes the opportunity to further comment on the
Public Health (Wales) Bill, and embraces this Bill alongside other
complementary legislation such as the Well-being of Future
Generations (Wales) Act, the Social Services and Well-being (Wales)
Act, Environment (Wales) Act and the Active Travel (Wales)
Act.
2.
This
Bill will help to ensure that the health and well-being of the
population is considered and
underpins the shared responsibility that all public bodies in Wales
have for the health of the nation. The Public Health (Wales) Bill
will add to the legislative framework for improving health and
well-being, protecting health and reducing inequalities in
Wales.
3.
The
following gives an update on relevant areas following our previous
submission dated 4th September 2015 (Appendix 1) which
should be read alongside this information.
4.
In
addition to the areas listed below, Public Health Wales strongly
supports the re-introduction of the draft Public Health (Minimum
Price for Alcohol) (Wales) Bill. Wales has the opportunity to
follow Scotland’s lead in taking forward this important
agenda, to reduce the substantial harm associated with excess
alcohol consumption in Wales. Our views on minimum unit pricing
were previously articulated in some detail in our submission to the
consultation on the White Paper. This is attached for information
as Appendix 2.
Part
2: Tobacco and Nicotine Products
5.
Public
Health Wales strongly supports the proposed action to protect the
Welsh population from harms associated with tobacco and nicotine
products. We have updated our previous evidence in Appendix 1, and
would further support the strengthening of proposals
through:
·
Extending
smoke free spaces into outdoor areas frequented by children and the
margins of buildings.
·
Having
a requirement for tobacco retailers to display information about
quit smoking support.
·
Have
a requirement for smoke free signs to include information on quit
smoking support.
Part
3: Special Procedures
6.
Minor
amendments have been made to Appendix 1.
Part
4: Intimate Piercing
7.
Minor
amendments have been made to Appendix 1.
Part
5: Health Impact Assessment
8.
We
welcome the inclusion of Health Impact Assessment (HIA) within the
Public Health (Wales) Bill as a statutory duty for public bodies in
Wales in specific circumstances.
9.
The
inclusion of HIA provides an opportunity to strengthen and
reinforce the commitment to Health in All Policies demonstrated in
the Well-being of Future Generations (Wales) Act. Public Health
Wales recommends that HIA should be a statutory requirement for key
policies and in other specified circumstances, with due regard for
proportionality, resource implications and cost. Legislating for
HIA would consistently ensure that all public bodies consider the
impact of their policies on health and well-being and inequalities
and would more effectively deliver the intention of a ‘Health
in All Policies’ approach. This would be a step change
to the current approach, where health and well-being is considered
in an inconsistent way.
10.
HIA
provides a systematic, objective, yet flexible and practical way of
assessing potential positive and negative, or unintended, health
and well-being impacts associated with a particular activity.
It also provides an opportunity to suggest ways in which health
risks can be minimized and health benefits and opportunities
maximized. A
major objective or purpose of an HIA is to inform and influence
decision-making. HIA can provide a valuable source of
evidence to be reviewed as part of any decision making process
across a wide range of sectors.
11.
As
practised in Wales, HIA views ‘health and well-being’
in a holistic way which encompasses mental, physical and social
well-being. Based on a social determinants framework,
HIA recognizes that there are many, often interrelated factors that
influence people’s health, from personal attributes and
individual lifestyle factors to socioeconomic, cultural and
environmental
considerations.
12.
HIA
includes both quantitative and qualitative data including,
importantly, community participation and stakeholder
knowledge.
13.
HIAs
generally take one of three forms in Wales – desktop, rapid
participatory or comprehensive. A desktop HIA may take only a
few hours or a day to execute, a rapid HIA may take a few days to a
few months to complete, and a comprehensive HIA is more in-depth
and time / resource intensive and can take many months or years to
complete. The most appropriate type to conduct can be decided
through a short scoping exercise, where timeframes, resources and
levels of stakeholder involvement are reviewed. Comprehensive HIAs,
whilst infrequent, can involve significant work but also provide
significant value especially in respect of involving communities
and private citizens. An illustration of such an approach can be
seen with historical HIAs e.g. Margam open cast mining and more
recently in the proposed Wylfa Newydd Nuclear Power Station in
Anglesey.
14.
A
number of the governmental strategic levers and drivers currently
exist and have been put in place to influence the use of HIA.
In a wide range of areas, including road and rail transport,
minerals,
waste
and land use planning
and regeneration
plans, HIAs are referred to in Welsh Government guidance. HIA
is also a mandatory requirement within the NHS in respect of
investment in infrastructure and capital build projects.
15.
It
would therefore appear a logical next step as part of the Public
Health (Wales) Bill to include provision for statutory HIAs in
these existing circumstances and build on this body of HIA work and
the requirements of the Well-being of Future Generations (Wales)
Act. Other areas which would benefit from undertaking HIAs would be
Public Services Board Well-being Plans; major Health Board or Local
Authority service re-configuration; incorporating HIA into
Environmental Impact Assessment requirements in Wales (thus
avoiding duplication of resources); permitting new fast food
outlets e.g. near schools; and for Welsh Government national
policies or plans of significant impact. For example, the Wales
Health Impact Assessment Support Unit (WHIASU), Public Health Wales
has recently supported a HIA for the new Night Time Economy
Framework. There could be a future role for WHIASU to support more
of this type of work. WHIASU can best add value by providing expert
advice on HIAs undertaken on national policies, large
infrastructure projects or projects involving multiple
agencies.
16.
We
believe that consideration needs to be given to capacity
requirements of a wide range of organisations (including Public
Health Wales) to develop systems, and ensure there is sufficient
support and skills to undertake HIAs. Public Health Wales, and
specifically WHIASU, has a clear role in supporting capacity
development through training and the provision of support such as
mentoring practitioners (and indeed much work has been successfully
undertaken in this area to date). However, WHIASU currently
consists of only 2.5 FTE posts and already provides wide ranging
expert support. We believe that additional requirements for HIA
would need to take into account current limited capacity within
WHIASU and any additional resources needed to deliver the defined
requirement(s) effectively and to a high standard.
17.
Legislating
for HIA will make a significant contribution to improving the
future health and well-being of the Welsh population, lead to more
effective policy making at the same time as enhancing Wales’
reputation as a world leader in the application of Sustainable
Development and public health policy.
Part
6: Pharmaceutical Services
18.
We
have no additional comments on pharmaceutical services.
Part
7: Provision of Toilets
19.
We
have no additional comments on the provision of toilets.
Finance
20.
We
have no additional comments on matters of finance.
Delegated
Powers
21.
We
have no additional comments on delegated powers.
About
Public Health Wales
22.
We
exist to protect and improve health and well-being and reduce
health inequalities for people in Wales. We work locally,
nationally and internationally with our partners and
communities.
Public Health Wales has four statutory functions. These are
to:
·
provide and manage a range of public health, health protection,
healthcare improvement, health advisory, child protection and
microbiological laboratory services and services relating to the
surveillance, prevention and control of communicable
diseases;
·
develop and maintain arrangements for making information about
matters related to the protection and improvement of health in
Wales available to the public; to undertake and commission research
into such matters and to contribute to the provision and
development of training in such matters;
·
undertake the systematic collection, analysis and dissemination of
information about the health of the people of Wales in particular
including cancer incidence, mortality and survival; and prevalence
of congenital anomalies; and
·
provide, manage, monitor, evaluate and conduct research into
screening of health conditions and screening of health related
matters.
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Appendix
1- this paper has been updated where appropriate
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Public
Health Wales NHS Trust
Response
to the Health and Social Care Committee Consultation on the Public
Health (Wales) Bill
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Date:
Previously
submitted 4 September 2015
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Version:1
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1
Overview
Public Health
Wales welcomes the opportunity to comment on the Public Health
(Wales) Bill.
The Welsh
Government has taken a number of steps in ensuring health is
considered across Governmental agendas in respect of legislation
such as the Active Travel (Wales) Act, Social Services and
Well-being (Wales) Act and the Well-being of Future Generations
(Wales) Act. The Public Health (Wales) Bill, although
relatively narrow in scope adds to the legislative framework for
health improvement and health protection.
Public Health
Wales believes that the proposed actions in the Bill will have a
positive impact on health and well-being in Wales and we look
forward to working with the Welsh Government to progress the
actions described.
Public Health Wales recognises that the Well-being of Future
Generations Act includes within it provision for a ‘health in
all policies’ approach which will raise the profile of
public health in society and increase awareness and knowledge of
public health issues across government departments (national and
local) and among those who develop and implement policy. This
approach in tackling the wider determinants of health is pivotal to
achieving the types of improvement in health and well-being and the
reduction in health inequalities that are required in
Wales.
The Public Health
(Wales) Bill provides an opportunity to reinforce Welsh
Government’s commitment to Health in All Policies through
inclusion of health impact assessment (HIA), which is not mandated
in the Well-being of Future Generations Act. Public Health Wales
recommends that HIA should be a statutory requirement for key
policies and other specified circumstances, with due regard for
proportionality, resource implications and cost.
In our response to
the White Paper we identified the need to define
‘well-being’ and that it was not appropriate for the
only definition and use of ‘well-being’ to be in the
Social Services and Well-being (Wales) Act. The Public Health Bill
must explicitly define well-being within its provisions and include
reference to physical, mental and social well-being.
2
Part
2: Tobacco and Nicotine Products
Public Health Wales fully supports the proposals
relating to tobacco and nicotine products contained in the
Bill.
Extending
restrictions on smoking in school grounds; playgrounds and hospital
grounds.
Restrictions on
the use of tobacco in public places serve two functions. The
first is to restrict exposure to environmental tobacco smoke (ETS)
to smokers and non-smokers. The second is to support the creation
of an environment in which non-smoking is the norm, in which
children in particular are exposed as infrequently as possible to
adults smoking. The introduction of smoking restrictions in outdoor
environments such as those listed above would support the second of
these. While voluntary bans may have merit, we believe that the
strong signal sent through legislation has more potential impact
and supports local authorities, health boards and others in
implementation – for example, we are aware of concerns from
those who work in Public Health at a local level that voluntary
smoking bans are problematic to enforce. It also assists members of
the public who can be certain as to whether or not they may smoke
in a setting regardless of where in Wales they are.
We support
proposals to prioritise the extension of current restrictions to
playgrounds; the grounds of hospitals and
schools. We would suggest that there would need to be a clear
definition of ‘playground’ and that
‘schools’ should include early years educational
settings such as nurseries (private and public). In the case
of schools and playgrounds this should include the perimeter of
these settings otherwise the intended impact of the restrictions is
unlikely to be achieved i.e. if parents or other adults are
permitted to smoke at the perimeter of a playground or at the
school gates in clear view of children this will not impact on the
intended goal of ‘denormalisation’ (reduce smoking
being modelled to children as normal behaviour). We would
also propose that the restrictions should not be limited to
hospitals but should include the grounds of premises used
predominately for the delivery of healthcare to include community
health facilities and primary care.
We would also
suggest that consideration is given to extending the requirement to
include signage indicating that the premises or outdoor area is
non-smoking to including information on signs (either a website or
telephone number) on access to smoking cessation
support.
Any additional
legislation will need to be accompanied by enforcement powers such
as Fixed Penalty Notice, although there will need to be
consideration of the enforcement approach as currently enforcement
is against the “person in control of premises” which
may be less applicable for playgrounds
Establishing
a national register of retailers of tobacco and nicotine
products
Public Health
Wales strongly supports this action, which is in line with Welsh
Government and local Tobacco Control Action Plans to reduce smoking
prevalence through prevention of uptake of smoking in young
people.
The introduction
of a register in Scotland has enabled the availability and trends
in availability of tobacco to be monitored effectively.
In addition to a
register of retailers, we support the view of the Wales Heads of
Environmental Health Group that the register should also cover all
those that manufacture, distribute and sell tobacco products.
This would ensure that the register covers other parts of the
tobacco chain. To support this, an offence should be created where
tobacco products can only be sold, distributed, etc to those
registered. However there is need to be mindful that the
aforementioned would appear to be covered by the recent HMRC
consultation ‘Tobacco Illicit
Trade Protocol – licensing of equipment and the supply
chain’. Although this consultation has closed consideration
should be given to including this provision should the proposal to
introduce the licensing system not progress.
We are concerned
about the use of the phrase “reasonable excuse” in
section 35(5) ‘A registered person who fails, without
reasonable excuse, to comply with section 30 (duty to notify
certain changes) commits an offence’. This term is not
defined in the legislation and may lead to evasion of enforcement
action.
Establishment
of a register to protect under 18s from accessing tobacco and
nicotine products
Enforcement of
underage sales is a key component of a strategy to prevent smoking
uptake. Supporting enforcement, in this case through a register,
would strongly enhance current measures. It is likely that the
measure will also support enforcement of display regulations.
Identifying locations where the sale of tobacco is permitted may
help with the identification of premises where tobacco is sold
illicitly.
We also believe
that the measure contributes to the denormalising of tobacco as a
product i.e. it is not the same as other consumer products and
should not be available for sale in the same way. The introduction
of registration re-enforces this position. We also believe
that over time it may be possible to use a register to monitor
systematically trends in illegal sales to young people – the
current important enforcement and intelligence based approach used
by local authorities does not enable Government or public health
agencies to understand whether there is a declining trend in
likelihood of non-compliance which would be a key goal of tobacco
control policy. We also believe that it would offer potential
to consider density of tobacco control outlets and their control by
local authorities as a public health measure in future.
Strengthened
Restricted Premises Order regime, with a national register, to aid
local authorities in enforcing tobacco and nicotine
offences
Public Health
Wales would support the proposal to enable Welsh Ministers to
extend the tobacco offences that may be counted toward the
application for a RPO.
Public Health
Wales remains concerned that the current enforcement programme and
resources available mean that it is highly unlikely that any
premises will be found to have infringed the regulations on three
occasions in a three year period and that in practice prohibition
is therefore unlikely. Anecdotal evidence from the current
enforcement of illegal sales legislation suggests that magistrates
are reluctant to impose the maximum fines even when cases are
brought to court. We would suggest that in the unlikely event of an
application for prohibition being brought the minimum
restriction on sales should be 12 months.
Our review of the
international evidence in this field supports the view that while
the introduction of legislation is important it will only be
effective if accompanied by active enforcement and a meaningful
deterrent. We remain concerned that this is not the case in
Wales at the current time.
Creating
a new offence for knowingly handing over tobacco and nicotine
products to a person under 18, which the is legal age of sale in
Wales
The growth of
online shopping would suggest the need to revisit all age
restricted sales in this way. The introduction of this new
offence is supported by Public Health Wales to ensure that all
tobacco products are requested and received only by an
adult.
Any
additional tobacco control measures which should be considered
for inclusion in the Bill
Wales
is currently well placed according to international comparisons in
the implementation of policy and legislation to minimise harm from
tobacco use. The main area for future development would
relate to hypothecated taxes or a levy on cigarette purchase or
profits. Work has been done that has demonstrated that the
normal competitive market forces do not operate for tobacco
products, with the tobacco market being dominated by a few large
multinational tobacco corporations. In addition, most notably
in California, a levy on every pack of cigarettes sold has funded
public health action; they now have among the lowest smoking rates
in the world. We recognise however, that these measures may
not be within the current legislative competence of the National
Assembly for Wales.
We would support
early implementation of the extension of the smoking ban in
enclosed public places to outdoor environments with a priority
given to hospital grounds; school grounds; playing fields and
outdoor leisure facilities; beaches and National Parks.
3
Part
3: Special Procedures
These proposals will certainly
improve the protection of public health. Recent experience
within Wales relating to a ‘look back’ exercise
conducted by Aneurin Bevan University Health Board in relation to
potential infection risk in Tattoo and body piercing parlours in
the area has highlighted the potential risk to Public Health from
these procedures. The proposals will mean that
basic conditions must be met prior to any special procedures being
undertaken. This, together with the strengthened local authority
powers to deal with non-compliance, will contribute to protecting
public health in Wales.
Creating
a compulsory, national licensing system for practitioners of
specified special procedures in Wales, and the approval of premises
or vehicle from which the practitioners operate
Public Health
Wales supports the proposal for a National Special Procedures
Register to ensure the provision of consistent standards in respect
of infection control, cleanliness and hygiene for all practitioners
and businesses operating any of the listed special
procedures.
There
is some older evidence that procedures such as piercing are a risk
factor for hepatitis, though actual occurrences may be rare. A
recent review suggests there is a significant risk of transmission
through piercing and tattooing procedures which are not done under
sterile conditions, such as at home or in prison. However, in our
view, the risk of transmission is the same in commercial parlours
where sterile conditions and infection control measures are not in
place. Scarring from complications following such procedures can
also have long-term psychological impacts. Anecdotal evidence
suggests that individuals with localised infections associated with
such procedures often present in GP practices and Accident and
Emergency departments, particularly following tongue piercings. All
of the nine cases identified in the look back exercise in Newport
self-presented to healthcare, often multiple times.
The
current legislation does not adequately protect the public and
these procedures have the potential to cause harm if not carried
out safely. In the recent look back exercise in Wales,
nine people were identified as needing hospital admission due to
severe Pseudomonas aureaginosa infection, eight of whom
required surgical intervention (including incision, drainage,
reconstruction and stitching), following body piercing at a tattoo
and body piercing premises. The individuals needed weeks of
hospital treatment and follow-up care, and some are permanently
disfigured. More minor problems for other clients included swelling
and trauma around the site, scarring, local skin infections, and
allergic reactions which were more prevalent. A lack of good
hygiene and infection control can lead to severe skin infections,
blood poisoning (sepsis) or transmission of blood-borne infections
through contaminated equipment, such Hepatitis B, Hepatitis C or
HIV.
The Register
should also consider requiring practitioners of special procedures
to have received a course of Hepatitis B vaccinations and routine
testing for blood borne viruses.
Types
of special procedures defined in the Bill
Public
Health Wales agrees with the types of procedures included within
the Bill and the acknowledgement that this is a changing field and
the need to include provision to amend the regulations accordingly.
In our initial response we had identified other procedures that
might be included within the scope of the Bill which have not been
included e.g. injections or fillers. This Bill also presents
an opportunity to regulate the administration of the following
procedures: body modification (to include stretching,
scarification, sub-dermal implantation/3D implants, branding and
tongue splitting), injection of any liquid into the body e.g. Botox
or dermal fillers, dental jewellery, chemical peels, and laser
treatments such as used for tattoo removal or in hair
removal.
We note that these
have not been included within the Bill, it is possible that this
will be encompassed within specific requirements for cosmetic
procedures in line with those proposed by the UK Government for
England following the Keogh Review in 2013
Provision
for Welsh Ministers to amend the list of special procedures through
secondary legislation
Public Health Wales is of the opinion that the
ability to amend the list of special procedures to enable the
inclusion and removal of specific procedures would enable the Welsh
Government to adapt and change legislation in accordance with new
trends and patterns in body modification.
Professions
that are exempt from needing a licence to practice special
procedures
The exemptions proposed include all
of the registered health professions. Further consideration would
be required as to whether all of the professions included within
the scope of this definition would have the necessary competence by
virtue of their professional registration to undertake these
procedures.
Impact
of enforcing the licensing system on local authorities
We support the view of the Wales
Heads of Environmental Health Group that the proposed licensing
system will enable local authorities to carry out their public
protection duties more effectively. The ability to recover costs
will provide local authorities with the finance to undertake their
enhanced role.
Health
risks associated with electrolysis and acupuncture
The
addendum addresses this matter. It is informed by a review of the
scientific literature since 2000 and by an analysis of the findings
from the look back exercise undertaken recently in Newport, Gwent
following concerns about skin infections identified in clients who
had used a piercing and tattoo studio.
Other
comments
Section 75 (5) of
the Bill (Special procedure licence: licence holder remedial action
notices) should be clarified so as to ensure that where there is a
risk to public health, there is the provision to stop an individual
undertaking procedures with immediate effect.
Public
Health Wales believes that the Bill should place a duty on
practitioners to check the age of those presenting for a special
procedure, as we do not believe it is sufficient to solely ask for
a client’s age. We would also advocate that the level of fine
for non compliance should be increased from level 3 to level
5.
We
have already highlighted other procedures that we believe need to
be regulated (body modification, injection of any liquid into the
body, laser treatments). Whilst these may be under review as part
of specific requirements for cosmetic procedures, we believe this
situation needs to be monitored closely to ensure that these
procedures are covered by a legislative framework.
4
Part
4: Intimate Piercing
Prohibiting
intimate piercing of anyone under the age of 16 in
Wales
Public Health Wales supports these
proposals.
Intimate
body parts defined in the Bill
We would also propose that the risks
posed by piercing of the lip also offer significant risks to the
health of children and that the scope of the proposed regulations
should be extended to include this area of the body.
Placing
a duty on local authorities to enforce the provisions, and to
provide local authorities with the power to enter premises, as set
out in the Bill
Public Health
Wales agrees with these proposals.
The
role of proposals relating to intimate piercing in contributing to
improving public health in Wales
Public Health Wales agrees that these proposals
will strengthen the protection of public health in Wales by
protecting some of the most vulnerable in our
population.
Implementing a minimum age restriction for all body
piercings
Public
Health Wales recognises that ear piercing in young children is
culturally accepted in some populations in Wales.
Current evidence
indicates that if there is parental consent and support for
ear piercing and if sterile
piercing equipment is used in a sterile and appropriate environment
and the correct aftercare is provided, then there is no
evidence of increased risk of infection in children.
As such, we do not
believe there is sufficient evidence to challenge current
practice.
5
Part
6: Pharmaceutical Services
Delivery of
additional pharmaceutical services at community pharmacies can
increase NHS capacity and improve access (location, extended
opening hours and availability of some services without an
appointment). The proposed changes mean that Health Boards
will be better able to identify which additional pharmaceutical
services they wish to commission, where, and at what times to meet
the needs of their populations.
Pharmaceutical
services are more likely to be considered as part of wider health
service planning and will be offered where there are advantages to
the population and Health Board. The proposed legislation will
also enable Health Boards to undertake service
redesign.
Overall, Public Health Wales is fully supportive
of the proposals outlined with the Bill in relation to
Pharmaceutical Services.
Improving
the planning and delivery of pharmaceutical services in
Wales
Public Health
Wales agrees that the proposals will improve the planning and
delivery of pharmaceutical services.
By undertaking a
Pharmaceutical Needs Assessment (PNA) and aligning the PNA with
other needs assessment and planning processes, Health Board
planning of pharmaceutical services is more likely to be integrated
and aligned with wider health needs assessment and health service
planning, rather than being undertaken in
isolation.
Encouraging
existing pharmacies to adapt and expand their services in response
to local needs
Under the
proposals, existing pharmacies will be encouraged to respond to
commissioner requests to deliver additional pharmaceutical services
to meet identified needs listed in the PNA. If the contractor
does not provide the services requested, they face the risk of
another contractor making a successful application to join the
pharmaceutical list in their area. Not only would the new
contractor provide the additional pharmaceutical services, but they
would also compete for NHS prescriptions and over-the-counter
sales, which are important sources of income for community pharmacy
contractors, thus leading to a potential loss of income for the
existing pharmacy.
Other
comments
Public
Health Wales believes that it is crucial that the
development of PNAs is aligned with wider Health Board planning and
commissioning.
6
Part
7: Provision of Toilets
Local
authority duty to prepare and publish a local toilets strategy for
its area
Public Health
Wales is in no doubt that the provision of toilets for public use
should be regarded as an important public health issue. We fully
recognise the challenges of safeguarding the existing provision or
improving provision in the current economic climate. Whilst the
preparation of a strategy that considers the need for and plans for
the future provision of toilets for public use would provide
clarity at the local level (for elected members, officers and the
public) the real issue of making resources available to address
this issue remains. The writing of a strategy alone will not
automatically improve provision.
Public Health
Wales recognises that access to toilet facilities when away from
home is an important public health issue, but precise quantitative
evidence of need is often lacking. Publicly accessible toilets are
a necessity to maintain population health for everyone, but some
groups have specific needs. These groups include people with
disability, parents with babies and young children, pregnant women,
older people and those with specific conditions including
incontinence, inflammatory bowel disease, irritable bowel syndrome,
multiple sclerosis, and people who have been prescribed diuretics.
If toilet provision is inadequate, people can become afraid or
reluctant to go leave their home for periods of time, leading to
poor mobility, isolation and depression.
Impact
of a local toilet strategy on improved provision of public
toilets
Public Health
Wales is cognisant of the financial pressures experienced by local
authorities at this time. Local authorities are best placed to
comment on their ability to safeguard existing provision and to
promote new facilities. A requirement to undertake health impact
assessment of changes to service provision and policy decisions
would inform the consideration of the adequacy of public toilet
provision in an area.
Ensuring
appropriate engagement with communities to guarantee the views of
local people are taken into account in the development of local
toilet strategies
Section 112 (1) of the Bill refers
not only to communities but includes “any person it considers
likely to be interested in the provision of toilets in its
area”. This should include not only local communities but
also, for example, those representing specific age groups, people
with disabilities or impairments or those with medical problems.
Consultation should also include the needs of homeless people,
mobile workers and visitors to the area. It is essential that
toilet provision should be adequate at transport hubs and in city
centres where local communities will be a minority of potential
users.
The
impact of Welsh Ministers’ ability to issue guidance on the
development of strategies
Guidance on the development of
strategies is likely to lead to a more consistent approach across
local authorities.
Toilet
facilities within settings in receipt of public funding
It would be useful if toilet
facilities could be made accessible to the public in settings such
as leisure centres, libraries, subsidised theatres, arts centres,
galleries and museums. This is already the case in some of these
venues but may not be widely known by some members of the public.
However, this would not be a complete answer to provision for
public use due to restricted opening hours.
Including
changing facilities for babies and for disabled people within the
term ‘toilets’ to ensure that the needs of all groups
are taken into account
Including changing facilities for
babies and for disabled people within the term
‘toilets’ is insufficient to ensure that the needs of
all groups are taken into account in the development of local
toilet strategies. Publicly accessible toilets are a
necessity to maintain population health for everyone, but some
groups have specific needs. These groups also include parents with
young children, pregnant women, older people and those with
specific conditions including incontinence, inflammatory bowel
disease, irritable bowel syndrome, multiple sclerosis, and people
who have been prescribed diuretics.
The
contribution of toilet provision to improving public
health
Provision of more toilets for public use should
contribute to improving public health, but only if they are well
designed and appropriately located with high standards of
maintenance and cleaning. Different categories of user and their
specific needs should be considered when making provision, as set
out above.
7 Finance questions
Costs
and benefits of implementing the Bill
We
have noted the costs and benefits of implementing the Bill in the
Regulatory Impact Assessment. Most of the additional costs of
implementing the Bill are borne by local authorities, Welsh
Government, businesses and local health boards.
The
economic downturn has resulted in strain being placed on public
bodies, including the NHS and local authorities. Any additional
duties mean that there is an opportunity cost around what can be
provided with limited resource available. As the proposed
legislation places significant additional duties on local
authorities, we believe that they should
be sufficiently funded to enable them to meet these requirements
e.g. through cost recovery.
Public
Health Wales believes that the Bill will help to improve and
protect the health of the population of Wales and that the costs
are proportionate.
Accuracy
and completeness of the estimates of costs and benefits identified
in the Regulatory Impact Assessment
The
Regulatory Impact Assessment provides detailed estimates of cost
and benefit.
Public
Health Wales is unable to comment on the accuracy of the costs to
other organisations.
Overall,
most costs and benefits appear to have been considered in the
Assessment, including costs to the health sector and health
benefits.
Financial
impact of the Bill on Public Health Wales
The
areas that may have a financial impact on Public Health Wales
are:
·
Special
Procedures
We
welcome the proposal to
include Public Health Wales in the development of guidance in
relation to special procedures, to assist practitioners and
businesses in their understanding of the legislation and its
requirements. This is likely to have opportunity costs for Public
Health Wales. We will address this through realigning our
priorities in order to meet this need.
·
Pharmaceutical
services - Pharmaceutical Needs Assessment
Public Health
Wales has been identified as a stakeholder in the task and finish
group to oversee and develop guidance to support local health
boards in undertaking a PNA and overseeing market exit. We note
that the anticipated resource implications for Public Health Wales
are three people attending up to half day meetings, costed at
£2,800. We anticipate that representation at these stakeholder
meetings will be from Pharmaceutical Public Health and Public
Health Wales Observatory. We agree with the proposed costings for
this.
We have also
identified that the Pharmaceutical Public Health Team, the Primary
Community and Integrated Care Team and the Public Health Wales
Observatory and potentially the IM&T Team are likely to need to
support local health boards with the content of the PNA, as well as
with stakeholder and public engagement. This may require the
development of webpages to achieve this.
Public Health
Wales, via its Integrated Medium Term Plan 2016-19, has committed
to supporting local health boards with the development of PNAs and
will be looking to prioritise work to ensure that it is able to
deliver this.
Additional
costs of the Bill’s proposals to businesses, local
authorities, community councils and local health boards
As
mentioned previously, most of the costs will borne by organisations
other than Public Health Wales.
Overall,
we consider that the additional costs are reasonable and
proportionate.
8 Delegated powers
Balance
between what is included on the face of the Bill and what is left
to subordinate legislation and guidance
We
agree that the Bill does contain a reasonable balance between what
is included in the Bill itself and what is included in subordinate
legislation.
We
have already commented on the need for subordinate regulation for
modifying the list of special procedures included in the
Bill.
Addendum
– Health risks associated with
electrolysis and acupuncture
a)
Summary of
evidence on Acupuncture, Electrolysis, Tattooing and
Piercing
A review of
evidence in scientific literature since 2000 examined the reported
impacts of the four special procedures outlined in the draft Public
Health Bill. This review identified 206 published articles
from across the world and reviewed them to draw out key
themes. The key points from this review were:
1 – Range
and severity of potential adverse consequences is consistent across
the four procedures.
Infections were the most commonly
reported adverse consequences in case reports for all procedures
identified. The causative agents for these infections were a
wide range of bacteria, including Haemophilus parainfluenzae,
Staphylococcus aureus, Listeria monocytogenes, Psuedomonas
species , Non-tuberculous Mycobacterium and
Enterococcus faecalis, and viruses (e.g. Hepatitis)
.
In interpreting these findings it is
important to note that the nature of the complications reported are
different depending on the nature of the study reporting
them. Cohort studies involving practitioner reporting of
complications generally show high levels of minor consequences
(e.g. minor bleeding, itching). This is a different picture
to the case reports published by medical professionals which
describe more unusual or severe outcomes and outbreaks. This
makes estimation of the prevalence of infections following the
procedures difficult.
Outbreaks of infectious disease have
been reported in the academic literature for all of the
special procedures listed. Similar causative agents (e.g.
Non-tuberculous Mycobacterium species or hepatitis virus)
are seen across these outbreaks.
The numbers of studies or reported
cases are not necessarily the same, but this may reflect
differences in prevalence of the procedure or management and
reporting of cases. This is exemplified by electrolysis where
only one study was identified within the time period and one older
outbreak was subsequently identified. This may reflect a
lower risk or a lower prevalence of the procedure being used
– there is not sufficient evidence to say which of these
applies.
As all procedures proposed in the
legislation involve piercing the skin with a needle and the skin is
the body’s first line of defence against infection there is a
prima facia case that the risks of infection posed by the
procedures are similar. This is apparent in the evidence identified
and for most procedures the organisms reported to be causing
infection are similar. It is therefore important to ensure
that standards of infection control and awareness of infections are
similar across the procedures.
2 – Risk of
severe outcome is dependent on type and location of procedure and
patient characteristics
With many of the
infectious adverse events the consequences range from minor
localised infection to fatal or life changing outcomes for the
case. There is evidence that there are a number of factors
which contribute to the severity of the outcome for patients.
These factors include susceptibility of the client to serious
infection and the body site where the procedure is carried
out.
It is clear that
diabetes and congenital heart conditions feature regularly in the
case reports of severe and fatal outcomes. It is also clear that in
some cases the client was aware of the condition but not that it
carried an increased risk for the procedure. The outcomes
including invasive group A streptococcus infection and infective
endocarditis carry large costs for health services (e.g. heart
valve transplant) and risks to the patient. Some evidence
suggests that risks can be reduced in these vulnerable cases by
good infection control or measures such as antibiotic
prophylaxis.
For some special
procedures specific locations and practices have been associated
with increased risk. In piercing there is evidence that some
piercing sites (high ear, tongue) carry substantially higher risks
of complications and subsequent infection than others. This
evidence of location specific risk does not exist for other special
procedures. It is clear that tongue piercing in particular
carries an especially high risk of complication for individuals,
including bacterial endocarditis, aspiration of jewellery and
dental issues, compared to other sites. Additionally, high
ear piercing was associated with a larger number of outbreaks
(mostly pseudomonas species) compared to other piercing
sites. Similarly dilution of black ink to create grey during
tattooing has been associated with a number of outbreaks of
Non-tuberculous mycobacterium in the UK and worldwide.
It is therefore
important that practitioners are equipped with sufficient knowledge
of the risks to vulnerable patients and the increased risks
associated with certain locations and practices in order to
minimise the risk for patients and the population. Studies of
practitioner knowledge in the UK suggest that this is not currently
the case and minimum standards of training have been
advocated.
Conclusion
Measures proposed
by the Public Health (Wales) Bill requiring minimum standards for
knowledge and practice for all special procedures to be set and
enforced are proportionate to reduce the risks faced and necessary
to protect public health. All four special procedures share
the same risk factor, a needle is used to pierce the skin.
Although each has technical differences, which alter the likelihood
of infection transmission and the severity of infection if
acquired, the similarity between the basic technique means that all
should be regulated in the same way. The case in Wales supporting
these conclusions has been reinforced by the findings from a recent
health protection incident in Newport, Gwent, as described in the
next section.
b)
Newport look
back
A cohort of people
at risk of infection following a body piercing or tattoo at a
premises under investigation (termed ‘at-risk cohort’)
was identified. This ‘at-risk cohort’ was identified
from client lists held at the premises and from people who
self-presented following media reports of the incident, either
through a Public Health Wales helpline or by directly attending a
clinic session for a blood borne virus screen. The cohort
represents only those who were known to the Health Board, and is
unlikely to include all those who attended the premises under
investigation.
In total 1069
people were included in this ‘at risk cohort’; 680 from
client lists, 337 from people contacting the Public Health Wales
helpline and considered to be at risk, and 44 who self presented at
a clinic session. Source of referral was not recorded for 8
people.
Age of
cohort
Figure 1
illustrates the age profile of those identified in the look back
exercise. The largest proportion are aged less than 18 years with
many under 16 years.
Figure 1.
Age1 and sex distribution of cohort of people considered
to be at risk of infection following a piercing or tattoo at the
premises under investigation (‘at-risk
cohort’)
1
Age
as at May 2015
Figure 2
illustrates those identified who reported having
‘intimate’ piercings. It is of note that almost 1 in 15
are under 16 years of age. There are many more under the age of
18.
Figure 2.
Proportion of individuals attending for a blood borne virus screen
reporting a body piercing at an intimate site (nipples and/or
genitals) by age group1
1
Age
as at May 2015
Evidence of
harm
Of the 628 who
reported having had a piercing in the previous two years, 215 (34%)
reported having had a skin infection following the piercing.
Infections were reported across all age groups. Forty-one of the
215 people (19%) reporting a skin infection stated that they had
contacted a health service about the infection. Ten reported
attending hospital. Twenty-nine percent (28/96 individuals) of
those aged less than 16 years reported an infection, compared to
35% of those 16 years or older (187/532).
Proof
of age
From table 1 it
can be seen that clients under the age of 18, and under 16 in
particular, are adding years to their true age to pass themselves
off as older. Requiring the practitioner to check proof of age is
necessary to overcome this issue.
Table 1:
Difference in self- reported
age1 and true age2 in 387 clients attending a
piercing/tattoo studio under investigation in Exercise Seren by age
at time of procedure3
|
|
|
|
|
|
|
|
|
Reported
age greater than true age
|
Exact
age match
|
Reported
age less than true age
|
|
|
|
|
|
|
|
|
|
|
|
>2
years
|
1-2
years
|
<1
year
|
|
<1
year
|
1-2
years
|
>
2 years
|
|
|
|
|
|
|
|
|
|
|
|
<13
|
0%
|
6%
|
38%
|
56%
|
0%
|
0%
|
0%
|
|
|
13
|
10%
|
10%
|
10%
|
70%
|
0%
|
0%
|
0%
|
|
|
14
|
13%
|
33%
|
8%
|
38%
|
4%
|
0%
|
4%
|
|
|
15
|
6%
|
15%
|
48%
|
29%
|
2%
|
0%
|
0%
|
|
|
16
|
8%
|
6%
|
12%
|
73%
|
1%
|
0%
|
0%
|
|
|
17
|
0%
|
29%
|
16%
|
52%
|
0%
|
3%
|
0%
|
|
|
18-25
|
1%
|
0%
|
3%
|
96%
|
0%
|
0%
|
0%
|
|
|
>25
|
0%
|
0%
|
0%
|
97%
|
0%
|
0%
|
3%
|
|
|
|
|
|
|
|
|
|
|
|
Total
|
4%
|
12%
|
17%
|
65%
|
1%
|
1%
|
1%
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1
Age
calculated by subtracting client date of birth from date of
procedure. Both dates obtained from piercing studio client
records
2
Age
calculated from dates of birth obtained by checking client’s
details against Welsh Demographics Service
3
First
known visit for piercing and/or tattoo. Clients reported more than
one visit and multiple procedures on same visit)
Appendix
2 – Minimum Unit Pricing Alcohol
Additional
Material from Public Health Wales NHS Trust Response to the
Consultation on the Public Health White Paper – Listening to
You Your Health Matters
Public Health
Wales shares the Welsh Government’s concerns regarding the
levels of alcohol related harm in Wales. We support the view that
the consideration of public health should be one of the statutory
licensing objectives under the Licensing Act 2003 and that all
other available controls should be maximised at the local level.
Most notably, the opportunities of the local development planning
process should be promoted to ensure that health impacts are taken
into account during local decision making. The Public Health
Wales evidence based position on the issue of Minimum Unit Price is
reproduced in full in our response, for completeness and accuracy,
recognising that there is a notable overlap with the evidence
presented in the White Paper.
Minimum
Unit Pricing
Given
the evidence base and public health considerations, do you agree
that the Welsh Government should introduce a Minimum Unit Price for
alcohol?
There is
compelling evidence that introducing a minimum unit price in Wales
would lead to significant improvements in health and well-being.
Recent decades have seen increases in alcohol consumption and
health harms associated with alcohol across Wales. These increases
are linked with real terms reductions in the cost of alcohol. A
minimum unit price is a targeted measure that will impact
beneficially on the heaviest drinkers and other groups particularly
at risk from alcohol related harms – such as young people.
Moderate drinkers will experience relatively little change in the
amount they have to pay for alcohol. The evidence for this is
presented below and as a result of this compelling evidence
Public Health Wales strongly supports implementation of the
minimum unit price for alcohol in Wales.
Minimum Unit Price
(MUP) sets a floor price for a unit of alcohol,
meaning that alcohol could not legally be sold below that price.
This would not increase the price of every drink, only those that
are sold below the minimum price; for example very cheap spirits,
beer and wine. MUP is based on two fundamental principles that are
widely supported by scientific evidence:,,
·
When
the price of alcohol increases consumption by most drinkers goes
down including, critically, consumption by hazardous and harmful
drinkers (i.e. heavier drinkers)
·
When
alcohol consumption in a population declines, rates of
alcohol-related harms also decline
Drinking alcohol
increases the risk of developing over 60 different health
problems
including a range of cancers, liver disease, high blood pressure,
injuries and a variety of mental health conditions. It also
increases the risk of causing harms to the health of
others.
UK Government
guidelines for the consumption of alcohol recommend that to limit
the harms from alcohol to their health: men should not regularly
(every day or most days of the week) drink more than the lower risk
guidelines of 3-4 units of alcohol (equivalent to a pint and a half
of 4 per cent alcohol by volume [ABV] beer) and women more than 2-3
units (equivalent to a 175 ml glass of wine).
The 2011 General
Lifestyle Survey (GLS)
showed that the percentage of persons that drank more than 3-4
units on at least one day in Wales (28 per cent) was similar to
Scotland (31 per cent) and England (31 per cent). Those
drinking more than 6-8 units on at least one day was the same in
Wales (15 per cent) as in England (15 per cent) and similar to
Scotland (16 per cent). Residents of England and Wales (13
per cent and 12 per cent respectively) were more likely than men in
Scotland (7 per cent) to have had an alcoholic drink on at least
five days in that week.
The Welsh Health
Survey
(2012) reported that around two in five (42 per cent) adults
reported drinking above the recommended guidelines on at least one
day in the past week, including 26 per cent who reported binge
drinking (drinking more than twice the daily guidelines). Men
were more likely than women to report drinking above the
recommended guidelines on at least one day in the past week (48 per
cent of men compared with 36 per cent of women) and to report binge
drinking (31 per cent of men, 21 per cent of women).
Importantly,
social surveys consistently record lower levels of consumption than
would be expected from data on alcohol sales, partly because people
often underestimate how much alcohol they consume.
Although alcohol
sales data are not available for Wales, 2012 sales data for the UK
show that consumption was estimated at 22 units per person per
week. This is a much greater level than recorded in surveys and
suggests that more people exceed weekly guidelines than surveys
would suggest.
The past four
decades have seen a rise in alcohol consumption and although the
reasons behind this are complex and multi-factorial, affordability
is a key factor.
It has been
reported that alcohol is 45 per cent more affordable than in 1980
and the increase in affordability of alcohol has been linked with
increased alcohol consumption and related health harms,,,.
Men and women in
the UK can now exceed recommended daily limits for about £1 if
they purchase inexpensive alcohol from supermarkets or other
off-trade outlets.
A 2005 review by
the World Health Organisation (WHO)
of 32 European alcohol strategies found that the most effective
measures to curb alcohol related health harms include changes to
price and availability.
By comparison
other measures (public service campaigns, education initiatives,
and voluntary self regulation preferred by the alcohol industry)
have more limited impacts on drinking patterns and
problems.
This evidence has
led several countries to consider MUP policy.
Do
you agree that a level of 50 pence per unit is appropriate? If not,
what level do you think would be appropriate?
Based on the
evidence provided here, Public Health Wales regards a level of 50
pence per unit MUP as an appropriate level at which to initially
establish a MUP. Sufficient
modelling has already been undertaken in England and elsewhere to
estimate the benefits that a 50 pence MUP would have on alcohol
consumption and related health harms. However, this is based on
current levels of affordability of alcohol (2014), and we consider
that MUP should be linked to an inflationary measure to ensure it
remains an effective measure to reduce alcohol health harms. Should
the introduction of MUP be delayed the initial MUP should be
adjusted from 50p to account for inflationary trends up to the
point of its introduction.
Both US and UK
data show that the heaviest drinkers gravitate towards the cheapest
alcohol,.
As a result MUP affects heavy drinkers’ consumption much more
than light or moderate drinkers. Consequently, MUP is a targeted
measure which primarily impacts heavy drinkers.
In
England, modelling suggests that a 50 pence MUP would result
in:
·
a
harmful drinker drinking 368 fewer units per year
·
a
moderate drinker drinking 11 fewer units per year
·
an
annual reduction in alcohol related deaths of 12.3 per cent and in
alcohol related hospital admissions of 10.3 per cent
Concerns around
the possibility of a hard-hitting impact on those with low incomes
have been a critical consideration of MUP debate,,
however, for the majority of people on low incomes who are
abstainers, light or moderate drinkers, the financial impacts of
MUP are very small.
While a moderate
drinker may see a small increase in costs of alcohol per year with
a MUP of 50 pence (around £43.17- £55.57,
however, this figure is based on the average drinker per annum),
this should be seen in the context of national costs from alcohol
related harms (health, social, economic and criminal justice) being
equivalent to around £900 per family. These harm-related costs
could be substantially reduced if a MUP was introduced.
Work in Scotland
suggests that an MUP of 50 pence per unit would reduce
alcohol-related hospital admissions in Scotland by 8,900 annually
and would reduce alcohol related criminal offences by 4,200, with a
total value of an estimated saving of £1.3 billion over 10
years.
The inclusion of
impacts of MUP on crime is an important health and well-being
consideration. Therefore, as well as harm to the individual who is
drinking, alcohol consumption can also impact the well-being of
wider society through reducing alcohol-related crime, including
those relating to violent, anti-social and disorderly behaviour,
acquisitive crime and criminal damage.
The Crime Survey
for England and Wales reports that within the year 2011/12 there
was 917,000 violent incidents where the victim believed the
offender(s) to be under the influence of alcohol, accounting for 47
per cent of violent offences that year. Alcohol routinely accounts
for over 40 per cent of all violent crimes committed
and, as well as youth violence, is strongly associated with
domestic violence, child abuse and self-directed violence (e.g.
suicide).
In Scotland 50 per
cent of people reported one or more harms as a result of someone
else’s drinking in the last year.
Modelling
undertaken for England and Scotland suggest a MUP of 50 pence would
reduce alcohol related violence.
A MUP of 50 pence
would not impact the cost of alcohol in licensed settings (e.g.
pubs) but would increase the cost of the cheapest alcohol sold in
off-licences settings (e.g. supermarkets). This is an important
affect as the difference in costs between the two settings is
driving health harming behaviours such as pre-loading with alcohol
especially in young people, before going out for a night.
Do
you agree that enforcing Minimum Unit Pricing for alcohol would
support the reduction in alcohol related harms? Please provide
evidence to support your answer, if available.
Public Health
Wales agrees that enforcing a MUP for alcohol would reduce alcohol
related harms. We have presented much of the evidence to
support this position in the above sections. We have provided some
additional information below.
MUP in Canada has
proved a successful measure for reducing alcohol-related harms;
including reducing alcohol-related deaths.
In British
Columbia with a population of 4.6million, a 10 per cent increase in
the average minimum price of all alcoholic beverages was associated
with a 9 per cent decrease in acute alcohol-attributable admissions
and a 9 per cent reduction in chronic alcohol-attributable
admissions two years later.
It was estimated from this that a 10 cent (approximately 6 pence)
increase in average minimum price was associated with 2 per cent
(166) fewer acute admissions in the first year and 3 per cent (275)
fewer chronic admissions two years later. Canada is one of six
countries that have introduced some form of MUP and in every case
the observed impacts on reducing consumption (and consequently
preventing related harms) have been larger than those
estimated.
The estimated
costs to the health service in Wales of alcohol-related harm are
between £70 and £85 million each year.
These costs have increased since the 1970s, as alcohol has become
more affordable and alcohol-related deaths and disease have
risen. Therefore, Wales appears to be price sensitive to
alcohol with harms increasing as alcohol becomes more
affordable.
Thus, the number
of alcohol-related deaths
for males in Wales from alcohol increased from 236 in 2002 to 311
in 2012. The corresponding increase for females was 34 per
cent from 127 to 193 deaths. The number over the last five years
has declined slightly from 541 in 2008 to 504 in 2012 but actually
rose again between 2011 and 2012.
Wales’s
(episode-based) rates for hospital admissions caused solely by
alcohol (e.g. alcoholic liver disease or alcohol poisoning) has
increased consistently from 2001/02 to 2011/12. Among females,
alcohol-specific admissions per 100,000 population increased from
2001/02 (274.4) to 2011/12 (335.5), with a comparable increase
among males (537.5 in 2001/02 to 675.5 in 2011/12).
When considering
alcohol specific conditions plus alcohol related conditions (those
that are caused by alcohol in some, but not in all cases; e.g.
stomach cancer and unintentional injury) in the past 10 years, the
overall rate in Wales has increased (1,280.9 in 2001/02 to 1,643.7
in 2011/12). This increase has been observed among females
(951.6 to 1,185.4) and males (1,650.5 to 2,158.0).
Many of the health
harms associated with alcohol fall disproportionately on the most
deprived communities, with levels of alcohol related deaths across
Wales increasing from the most affluent to the most deprived
quintile. Consequently, tackling alcohol related ill health is an
important element in reducing inequalities in health.
Based on evidence
from Canada and elsewhere, MUP would help substantially in
reversing these health harming trends relating to alcohol
consumption in Wales.
As
the Welsh Government cannot legislate on the licensing of the sale
and supply of alcohol, what enforcement and/or penalty arrangements
do you think should be in place to introduce Minimum Unit Pricing
for alcohol in Wales?
Public Health
Wales is not currently in a position to provide specialist legal
advice on the implementation of a Minimum Unit Price for alcohol
across Wales. However, we would suggest the points below are taken
into consideration:
•
We are aware the issue of compatibility between European law and
MUP has been raised as an issue. We understand that certain
articles prohibit quantitative restrictions between Member States
on the Union’s founding principle that goods must be able to
move freely between Member States
•
Opponents to MUP argue that if goods are subjected to minimum
prices in one Member State this could act as a barrier to the free
movement of such goods
•
However, European law stipulates that such articles do not preclude
consideration of public morality, public policy or the protection
of health and the lives of humans. In other words measures such as
MUP could be introduced when the public health case is sufficiently
strong
•
Any measures implemented on the basis of Public Health must be
proportionate. In other words it is important to demonstrate that
public health benefits sought justify the measures implemented and
that the same outcome would not be achievable by a less intrusive
measure
•
Public Health Wales believes that there is a strong case across
Wales that MUP is a measure proportionate to expected reductions in
health harms and numbers of lives saved
•
Further, we understand that when raised by the Association of
Greater Manchester Authorities, their legal advice refuted the
claim that minimum pricing imposed at the sole instigation of a
public authority would be an infringement of national and EU
competition law
•
As the measure that is likely to at least involve consideration of
law changes and how they would impact public health, Public Health
Wales is keen to work with Welsh Government on the possible options
to implement MUP
•
Public Health Wales would suggest the implementation of bye laws
across Wales be explored alongside the use of existing licensing
legislation that allows conditions to be attached to alcohol
licenses
•
As well as legislative measures, it may also be worth considering
opportunities to allow additional freedoms and incentives to those
who operate a MUP policy on the basis that they are not
contributing to the costs resulting from sales of cheap alcohol
that fall on health, criminal justice, education systems and the
broader economy
•
A number of local authorities in England and Wales have taken steps
towards implementing MUP. Wales would be well placed to bring these
players together to share learning and provide leadership for
authorities wishing to tackle alcohol related harms to health
through MUP. Public Health Wales would be keen to support such a
forum with the support of the Welsh Government
Do
you think there are other measures that should be pursued in order
to reduce the harms associated with excessive alcohol
consumption?
Public Health
Wales recommends a range of other evidence based measures should be
considered in order to reduce the harms caused by alcohol to Welsh
citizens. None of these require MUP so are not dependent on MUP
being in place but would work in synergy to reduce alcohol harms to
health. Not all of these measures can be unilaterally
implemented in Wales as devolved powers do not allow their
introduction. However, we believe Wales can still act as a powerful
advocate for creating a culture where people are better informed
about the harms associated with alcohol consumption and the real
costs of alcohol are reflected in the price at which it is sold.
Further work is required to identify the best way of delivering
these through action and advocacy within existing devolved powers.
While provision of evidence to support all the actions suggested
below would be inappropriate in this consultation we believe there
is sufficient evidence already available to
support7:
·
Public
health and community safety should be given priority in all public
policy-making about alcohol
·
At
least one third of every alcohol product label is an evidence based
health warning from an independent regulatory body
·
Sales
in shops should be restricted to specific times of the day and
designated areas with no promotion outside these areas
·
Tax on
alcohol products should be proportionate to volume of alcohol to
incentivise sales of lower strength products
·
Licensing
authorities should be empowered to tackle alcohol-related harm by
controlling total availability in their area
·
Alcohol
advertising should be strictly limited to newspapers and other
adult press while its content should be limited to factual
information
·
There
should be an independent body to regulate alcohol promotion,
including product and packaging design for public health and
community safety
·
The
legal limit for blood alcohol concentration for drivers should be
reduced to 50mg/100ml.
·
Graduated driver
licensing should be introduced, restricting the circumstances in
which young and novice drivers can drive
·
All
health and social care professionals should be trained to provide
early identification and brief alcohol advice
·
People
who need support for alcohol problems should be routinely referred
to specialist alcohol services for assessment and
treatment
·
Existing laws to
prohibit the sale of alcohol to individuals who are already heavily
intoxicated should be enforced in order to reduce acute and long
term harms to their health and that of the individuals
around
them.
Welsh Transport
Appraisal Guidance (WelTAG).
Welsh Government 2008
‘Construction,
Infrastructure and Markets’ Wales Waste Strategy Sector Plan
. Welsh Government, 2012
Office for
National Statistics, (2011) ‘General Lifestyle
Survey’ [online] Available at:
http://www.ons.gov.uk/ons/rel/ghs/general-lifestyle-survey/2011/index.html
Welsh Government (2012) ‘Welsh Health
Survey’ [online] Available at:
http://wales.gov.uk/statistics-and-research/welsh-health-survey/?lang=en
WHO. Alcohol
policy in the WHO European Region: current status and the way
forward.
Institute for
Social Marketing: University of Stirling (2013) ‘Health
First: An evidence-based strategy for the UK’ [online]
Available at:
http://www.stir.ac.uk/management/about/social-marketing/
Home Office
(2012) A minimum unit price for alcohol: impact assessment
1A. Home Office, London, UK.
Anderson, P., Chisholm, D. and Fuhr,
D. (2009) Alcohol and Global Health 2: Effectiveness and
cost-effectiveness of policies and programmes to reduce the harm
caused by alcohol. Lancet, 373,
2234–46.
Gallet, C.A. (2007) The demand for
alcohol: a meta-analysis of elasticities. Austalian Journal of
Agriculture and Resource Economics, 51,
121-35.
Institute for Social Marketing:
University of Stirling (2013) ‘Health First: An
evidence-based strategy for the UK’ [online] Available
at:
http://www.stir.ac.uk/management/about/social-marketing/
WHO fact sheet. 2005.
www.parpa.pl/download/fs1005e2.pdf.
Kerr, W. C. and T. K. Greenfield
(2007). "Distribution of alcohol consumption and expenditures and
the impact of improved measurement on coverage of alcohol sales in
the 2000 National Alcohol Survey." Alcoholism: Clinical and
Experimental Research, 31, 1714-1722.
Meier, P., Brennan, A., Purshouse,
R., Taylor, K., Raffia, R., Booth, A., O’Reilly, D.,
Stockwell, T., Sutton, A., Wilkinson, A. and Wong, R. (2008)
Independent review of the effects of alcohol pricing and
promotion, Part B. Modelling the Potential Impact of Pricing and
Promotion Policies for Alcohol in England: Results from the
Sheffield Alcohol Policy Model, Version 2008(1-1). University
of Sheffield, Sheffield, UK. Report commissioned by the UK
Department of Health.