Lessons from Wales — how to embed sustainability and prevention in health care

Legislation and policy support step change for public services in tackling societal challenges in a sustainable way

Across the globe, United Nations member states are considering the 17 new Sustainable Development Goals, targets and indicators that collectively focus on ending poverty and hunger, improving health and education, making cities more sustainable, and combating climate change.1 Wales is one of the first nations in the world to establish a legislative link to the international Sustainable Development Goals, through the creation of the Well-being of Future Generations (Wales) Act 2015. The ambitious Welsh legislation provides an opportunity for a step change in the way public services tackle some of the main health and other societal challenges that will serve and sustain future generations.

Overall, the health of the Welsh population is improving steadily, but the conditions for good health, on equal terms for the entire population, remain a concern. The reasons for these differences are diverse and have roots deep in the history of the communities concerned. They are linked to poverty, social conditions, geographic location and lifestyles, and these also influence each other.

Legislation is arguably one of the most powerful tools available to governments to direct long-term policy goals. It can be an effective lever for influencing changes in society and provide a platform for directing action for the benefit of whole populations. In the case of the Well-being of Future Generations (Wales) Act, it is the recognition that Welsh public services, through leadership and improved capability, are uniquely placed to support individuals and communities to maintain, improve and sustain their health and wellbeing. To this end, the Act places a new duty on national and local public services, no matter what their specific responsibilities, to maximise their contribution to improving the economic, social, environmental and cultural wellbeing of the country. From April 2016, all public bodies will work towards a legally binding common purpose, set out in s 4 of the Act as seven statutory wellbeing goals (Box 1).

Public bodies will be required to set and work towards wellbeing objectives that will maximise their individual contribution to achieving the goals. They will also be required to work together through newly established public services boards, consisting of the main statutory partners; to collectively assess and publish a report on the state of wellbeing in the area, which in turn will inform the development of their local wellbeing plan.

The Act also defines sustainable development as a way of doing things rather than as an end in itself. It requires public bodies to use sustainable development to shape what they do, how they do it and how it is communicated. The five components of the sustainable development principle are set out in s 5 of the Act. These “ways of working” are familiar to those involved in public health (Box 2).

Monitoring and accountability structures, based on the goals and principles, are built into the legislation. For example, the Auditor General for Wales will seek evidence from public services, including the Welsh Government, in order to demonstrate how public bodies have taken the long term into account, have prevented problems from occurring or getting worse, have taken an integrated approach and worked in a collaborative way, and have involved people in policy making, planning and the delivery of services. A Future Generations Commissioner has been appointed and a consultation launched on measures to assess progress.2

The Act represents a milestone for public health — its definition (physical and mental wellbeing) and parity with other goals — with health and equality goals both integral parts and prerequisites for sustainable development. The “health in all policies” approach — described as “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity”3 — is embedded. Without good health we cannot enjoy a sense of wellbeing and cannot participate in the economy and contribute to social capital. The Act therefore helps articulate an understanding of the determinants of health, helping us to see good health not only as a result of access to quality health care, but being based on socioeconomic status, early intervention and prevention policies, enabling physical environments, as well as individual genetics and behavioural choices, thus moving towards an ecological approach to health and wellbeing.

Although healthy life expectancy is improving, Wales has about a third of its population living with chronic conditions, many of which are preventable.4 The health care system therefore must also respond to the current need as well as build a more sustainable approach for the future. Further legislation comes into force in April 2016 — the Social Services and Well-being (Wales) Act 2014 will drive a change in the care system towards a more preventive approach, integrated around individual needs.

Alongside this has emerged the concept of prudent health care focused on achieving a sustainable health care system.5 Four prudent health care principles were proposed by the government’s advisory body, the Bevan Commission, and endorsed by the Minister for Health and Social Services (Box 3).6

Sustainability and equity are central to a prudent approach to health care. It is about using resources with careful thought as to what is appropriate to the needs of each individual and not always to do everything that is technically possible, as this cannot always match everyone’s hopes and expectations. The National Health Service needs to introduce new discoveries quickly, where appropriate, while recognising that simpler treatments can be just as good or better for many patients. Many health care systems are adopting similar approaches.7

Prudent health care is based on a robust primary care system that is founded on strong co-production: “an approach to public services which enables citizens and professional to share power and work together in equal partnership”.5 This means shifting the emphasis of care from hospitals to community settings, working closely with other services that can underpin healthier lives, and embracing a wider social model of care rather than a purely medical one.

There are challenges for staff in a prudent health care system that requires a genuinely equal balance in decision making between the service user and the professional. We know that patients do better when they determine their own plan for care. In adult social services, for example, we have seen that adopting the principle and purpose of a prudent approach has resulted in empowered staff and service users, a reduction in staff hours and resource use, and the delivery of a service that people prefer.5

Evidence gathered in recent years suggests that we do more and more to people but their experience and the outcome does not always improve as a result. The idea that often to do less is to do better for people can be difficult to accept in a world where the benefits of every new technology and test are promoted. Prudent health care should achieve better health outcomes, better quality, and better value.6 During 2016, the Well-being of Future Generations (Wales) Act and the Social Services and Well-being (Wales) Act will be implemented. Coupled with the move to embedding prudent health care principles into services, this will help Wales to make progress towards a sustainable health and wellbeing system.