The new Public Health (Wales) Bill

07 November 2016

Article by Philippa Watkins, National Assembly for Wales Research Service

Darllenwch yr erthygl yma yn Gymraeg | View this post in Welsh

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The Public Health (Wales) Bill was introduced on 7 November 2016. This is the second time the Welsh Government has brought forward such a Bill – the previous Government introduced its Public Health (Wales) Bill in June 2015. That Bill was rejected at Stage 4 in March 2016.

Our 20 October blog post The Public Health (Wales) Bill as introduced in the Fourth Assembly summarises the progress made by the previous Bill. The proposals to restrict the use of e-cigarettes in public places are not included in the Bill introduced this week and are not discussed here. The Bill is otherwise practically identical to the previous Public Health Bill as amended at stage 3.

This article provides some additional background information on elements of the Bill which were the subject of greater debate in the Fourth Assembly, or which were added to the Bill during the amending stages. This includes special procedures, additional smoke-free premises (school grounds, hospital grounds, public playgrounds), and health impact assessments.

Most elements of the Bill proved non-contentious. The chapters dealing with pharmaceutical services and provision of toilets for public use had broad support among stakeholders and Members of the previous Health and Social Care Committee. The proposals to create a national register of retailers of tobacco and nicotine products, and to prohibit the handing over of tobacco etc. to under 18s, were also largely welcomed. More detailed scrutiny focused on the chapters dealing with special procedures and intimate piercing, the main issue here being whether additional procedures should be captured by the Bill. The provisions about the additional smoke-free premises and health impact assessments were added at stage 3.

Special procedures

The previous Health and Social Care Committee took evidence from a wide range of stakeholders on the proposal to create a mandatory licensing scheme for practitioners and businesses carrying out certain special procedures. It agreed that there was sufficient risk of public health harm to support the need for a licensing scheme covering tattooing, piercing, acupuncture and electrolysis, as set out in the Bill. The Welsh Government’s rationale for specifying these four procedures on the face of the Bill is that these are all commonly performed, and there is sufficient evidence of the potential risk of infection to warrant their inclusion.

The Committee was concerned to hear about some more extreme body modification procedures (such as tongue splitting, branding, scarification and sub-dermal implants). It’s not known how commonly these types of procedures are carried out, but there was concern about the potential for harm. Particularly if, as some witnesses reported, such invasive procedures are undertaken by people with limited knowledge of anatomy or infection control, or ability to manage complications. The Committee was similarly concerned about the risk of harm from non-surgical cosmetic procedures if poorly administered (this includes procedures such as botox, dermal fillers, chemical peels etc.). The Committee believed there may be a case for body modification procedures and non-surgical cosmetic procedures to be added to the Bill.

Non-surgical cosmetic procedures were the subject of a UK review of the regulation of cosmetic interventions in 2013. The previous Committee, and the Minister, noted their disappointment at the lack of progress in implementing the review’s recommendations. Responding to the Committee’s stage 1 report, the Minister stated that if he did not receive sufficient assurance about UK Government proposals to regulate these procedures, he would consider alternative courses of action. This could include using the Bill’s regulation-making power to amend the list of special procedures.

Opposition amendments to add certain body modification procedures to the Bill were not agreed at stage 2. The then Minister stated that a greater exploration of the associated risks of harm was needed before considering adding them to the legislation. He put on record his intention to consult early on the principle of adding more procedures to the list shortly after the Bill’s enactment. There is provision in the new Bill to add to the list of special procedures (or to remove procedures) to take account of new practices and changing trends, and any emerging evidence of public health risk.

The proposal to prohibit intimate piercing being carried out on under 16s received widespread support. The Committee heard significant concern about the risks of tongue piercing, and the tongue was subsequently added to the list of intimate body parts included on the face of the Bill.

Smoke-free premises

Additional smoke-free premises – school grounds, hospital grounds, and public playgrounds – were added to the Fourth Assembly Public Health Bill at stage 3. The Bill also included provision to add additional smoke-free premises via regulations ‘if the Welsh Ministers are satisfied that doing so is likely to contribute towards the promotion of the health of the people of Wales’. This is replicated in the new Bill.

The Explanatory Memorandum (EM) states that restricting smoking in non-enclosed spaces such as hospital grounds, school grounds and children’s playgrounds would contribute to the de-normalisation of smoking, by providing fewer opportunities for the activity of smoking to be seen. Voluntary bans are in place in many areas, though difficulties in enforcing these have been reported, and the legislation is intended to aid enforcement.

In addition, the provisions relating to hospital grounds are intended to promote behaviour change and support smoking cessation among smokers who use hospital services.

Obesity and physical inactivity/Health impact assessment

During the Fourth Assembly, there was concern among stakeholders about the lack of actions to tackle obesity and physical inactivity in the Bill as introduced. The Welsh Government emphasised that the Public Health Bill shouldn’t be seen in isolation, but viewed alongside other legislation such as the Active Travel (Wales) Act 2013 and Well-being of Future Generations (Wales) Act 2015. The Government stated that it continued to consider a range of actions to tackle obesity in Wales, ‘the majority of which do not require primary legislation or could be considered using existing legislative powers’.

Stakeholders pushed for mandatory health impact assessments (HIA) to be included in the Bill. The British Medical Association, supported by 22 other organisations including professional bodies and voluntary sector organisations, called for HIA to be placed on a statutory footing. It suggested that a requirement for the use of HIA should be included on the face of the Bill, with the circumstances in which a mandatory HIA is needed to be set out in regulations.

In the first instance we would suggest that these regulations could require that HIA is made mandatory in relation to Strategic and Local Development Plans, certain larger scale planning applications, the development of new transport infrastructure, Welsh Government legislation, certain statutory plans such as Local Well-being Plans, new NHS developments (e.g. new hospitals) and health service reconfiguration proposals.

At stage 2 the Welsh Government committed to bring forward a stage 3 amendment to include HIA on the face of the Bill. This reflected the Health and Social Care Committee’s recommendation at stage 1 to introduce a requirement to undertake mandatory HIA when developing certain policies, plans or programmes. (Opposition amendments in this area had been tabled at stage 2, but were not moved in light of the commitment given by the Minister).

The new Public Health (Wales) Bill as introduced places a duty on the Welsh Ministers to make regulations which require public bodies to carry out HIA in specified circumstances.

In the EM, HIA are described as offering ‘a systematic means of taking health into account as part of decision making and planning processes. They are a tool which can be used in any area of public, private or voluntary sector activity, and at both national and local levels’.

The EM highlights that HIA already takes place across Wales, supported by a dedicated Welsh Health Impact Support Unit (WHIASU) within Public Health Wales. The Bill seeks to strengthen the current position by making the use of HIA mandatory in specified circumstances.

The Bill aims to take a proportionate approach – assessments would be limited to policies, plans and programmes which have outcomes of national or major significance, or which have a significant effect at the local level on public health. The EM states that the regulations setting out the circumstances and manner in which public bodies must carry out HIA will be developed through consultation and will be subject to approval by the Assembly under the affirmative procedure.

To ensure alignment with the Well-being of Future Generations Act, it’s proposed that all of the public bodies covered by that Act will also be covered by the requirements to carry out HIA.

The Public Health (Wales) Bill as introduced in the Fourth Assembly

20 October 2016

Article by Philippa Watkins, National Assembly for Wales Research Service

Darllenwch yr erthygl yma yn Gymraeg | View this post in Welsh

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The previous Welsh Government introduced its Public Health (Wales) Bill in June 2015. The Bill set out a series of specific proposals in priority areas of public health policy. It aimed to create social conditions that are conducive to good health and where avoidable harms can be prevented.

The Welsh Government is expected to reintroduce the Public Health Bill in November. It has previously stated that this will be in the form of the previous Bill as amended at stage 3, but without the sections restricting the use of electronic cigarettes in enclosed public places.

The Bill included provision for the following:

Tobacco and nicotine products

  • Restricting the use of nicotine inhaling devices such as electronic cigarettes in enclosed and substantially enclosed public and work places, bringing the use of these devices into line with existing provisions on smoking.
  • Creating a national register of retailers of tobacco and nicotine products.
  • Adding to the offences which contribute to a Restricted Premises Order (RPO). (An RPO prohibits the sale of tobacco products from a premises).
  • Prohibiting the handing over of tobacco or nicotine products to people under the age of 18.

Special procedures

  • Creating a mandatory licensing scheme to regulate practitioners and businesses carrying out ’special procedures’, namely acupuncture, body piercing, electrolysis and tattooing.
  • Introducing a ban on the intimate piercing of people under 16 years old.

Pharmaceutical services

  • Changing the way Health Boards make decisions about pharmaceutical services by making sure these are based on assessments of pharmaceutical need in their areas.

Provision of toilets

  • Requiring local authorities to prepare local toilets strategies for the provision of, and access to, toilets for public use, based on the needs of their communities.

Key changes made at stage 2

Stage 2 was carried out in the Health and Social Care Committee in January and February 2016. A number of amendments were agreed. In addition, the then Minister for Health and Social Services, Mark Drakeford, indicated that the Welsh Government would bring forward, or consider, further amendments in a number of areas at stage 3.

Part 2 Tobacco and nicotine products

Treating tobacco and nicotine inhaling devices differently

In the Bill as introduced, the use of nicotine inhaling devices (NIDs) was placed under the same restriction in public places/workplaces as smoking tobacco cigarettes. The most significant change to this part of the Bill at stage 2 resulted from amendments which set out different approaches for tobacco and for NIDs in terms of restricting their use. This was in response to concerns that treating tobacco and NIDs in the same way could send out a message that they are equally harmful.

**As noted earlier, the provisions restricting the use of nicotine inhaling devices in enclosed public places will not now be brought forward**

Extending the restriction to other, non-enclosed areas

Opposition amendments to place a ban on smoking tobacco in non-enclosed children’s play areas, school grounds, and hospital grounds onto the face of the Bill were not agreed at stage 2. The Minister indicated that he would be willing to consider bringing forward Government amendments at stage 3.

Part 3 Special procedures

The list of special procedures (acupuncture, body piercing, electrolysis, tattooing) on the face of the Bill remained unchanged. Opposition amendments to add branding, scarification, sub-dermal implantation and tongue splitting to the list were not agreed at stage 2. The Minister stated that a greater exploration of the associated risks of harm was needed before considering adding them to the legislation.

The Minister did note an intention to consult early on the principle of adding more procedures to the list shortly after the Bill’s enactment, stating that the consultation will include the above procedures, and also others that were identified during the passage of the Bill so far, such as dermal rolling, colonic irrigation, and wet cupping.

Licensing criteria and conditions

Amendments were passed to add key licensing criteria to the face of the Bill. Applicants would be required to demonstrate knowledge of infection control and first aid in the context of the relevant special procedure. Applicants must also demonstrate knowledge of the duties imposed on them as a person authorised to perform a special procedure.

The mandatory licensing conditions (which control the conduct of practitioners who have received a license) were also amended to include conditions covering proof of age of an individual on whom a special procedure is to be performed, infection control, and first aid. The mandatory licensing conditions, specified in regulations, must also relate to intoxication, to prevent a licence holder from performing a special procedure on an individual who is, or who appears to be, intoxicated by virtue of drink, drugs or any other means.

Level of fine imposed

Amendments were passed to remove the limit on the fine associated with offences in relation to special procedures, amending it from a level 3 to an unlimited fine.

Part 4 Intimate piercing

Tongue piercing

The tongue was added to the list of intimate body parts listed on the face of the Bill in relation to intimate piercing restrictions, due to the associated risk of harm. This means it would be an offence to perform, or make arrangements to perform, a tongue piercing on a person who is under the age of 16 years.

Level of fine imposed

Amendments were passed to remove the limit on the fine associated with the offence of performing, or making arrangements to perform, an intimate piercing on a child from a level 4 to an unlimited fine.

Part 5 Pharmaceutical services

No amendments were agreed to this part of the Bill at stage 2.

Part 6 Provision of toilets

This part of the Bill was amended at stage 2 to require that Welsh Ministers must (rather than ‘may’) issue guidance to support local authorities when developing their local toilets strategies, and to set out in more detail what the guidance must include.

Additionally, the Bill was amended to require local authorities to prepare and publish interim progress statements (as recommended by the Health and Social Care Committee at stage 1). This was a new requirement, and was in addition to the duty on local authorities (in the Bill as introduced) to fully review their strategies no later than one year after the end of an electoral term.

Part 7 Miscellaneous – food hygiene rating offences

The Bill was amended at stage 2 to make a minor technical amendment to the Food Hygiene Rating (Wales) Act 2013 so that the receipts from fixed penalty notices for non-compliance with the food hygiene rating scheme must be used by food authorities (primarily local authorities) to enforce the scheme. This will bring the Food Hygiene Rating (Wales) Act into line with the provisions of the Public Health (Wales) Bill, under which receipts from fixed penalty notices issued under Chapters 1 and 2 of Part 1 must be used by enforcement authorities to support the new duties imposed on them in these chapters of the Bill.

Health impact assessment

During stage 2, the Welsh Government committed to bring forward a stage 3 amendment to include health impact assessment (HIA) on the face of the Bill. HIA is a process which considers the extent to which the health and well-being of a population may be affected, whether positively or negatively, by a proposed policy, plan or programme.

At stage 1, the Health and Social Care Committee heard from stakeholders that mandatory HIA would provide a mechanism to avoid or minimise negative impacts on the health and well-being of communities, and maximise health benefits where possible. The Committee’s stage 1 report recommended that the Bill be amended to include a requirement to undertake mandatory HIAs when developing certain policies or plans.

Opposition amendments in this area had been tabled at stage 2, but were not moved in light of the commitment given by the Minister.

Key changes made at stage 3

As indicated at stage 2, the Bill was amended at stage 3 by Welsh Government amendments introducing a requirement for public bodies to carry out health impact assessments. The circumstances in which health impact assessments must be undertaken would be specified in regulations.

Welsh Government amendments were agreed which set out additional, non-enclosed areas where smoking and use of nicotine inhaling devices would be restricted, namely school grounds, hospital grounds, and public playgrounds.

Further reading

Key documents relating to the Bill, including Explanatory Memoranda, Committee reports, and transcripts of proceedings can be accessed via the Public Health (Wales) Bill web page

E-cigarettes – balancing the risks and benefits for public health in Wales

2 September 2015

Article by Philippa Watkins, National Assembly for Wales Research Service

Image by Mike Mozart via flickr, licensed under Creative Commons.

Image by Mike Mozart via flickr, licensed under Creative Commons.

The Assembly’s Health and Social Care Committee will continue its scrutiny of the Public Health (Wales) Bill in the autumn term. It is the proposals to restrict the use of e-cigarettes in public places that are attracting the most attention and controversy.

Evidence sessions to date have covered all elements of the Bill – proposals relating to provision of toilets, pharmaceutical services, special procedures (tattooing, piercing etc.), and tobacco and nicotine products. In the autumn, the Committee will be seeking further evidence on the e-cigarette proposals from a wide range of stakeholders.

The Committee has already taken evidence from public and environmental health experts and representatives of local government. So far, there’s been strong support for the proposals to bring the use of e-cigarettes in line with the smoking ban. Whilst acknowledging that e-cigarettes may have a role in smoking harm-reduction, witnesses have argued that allowing the widespread use of e-cigarettes in public places risks undermining progress made so far in reducing the uptake and prevalence of smoking, and poses a significant challenge to enforcement of the smoking ban.

The Committee is likely to hear contrasting views in upcoming evidence sessions; even within the medical community, experts are divided on the issue.

A key point that’s expected to be discussed is the extent to which e-cigarettes actually represent a potential public health gain. If e-cigarettes helped large numbers of smokers to quit tobacco, this could have a significant impact on reducing smoking-related deaths and disease. It’s important to be clear that the Bill’s proposals do not prevent people from buying or using e-cigarettes, but there are concerns that smokers may be discouraged from switching to e-cigarettes if they are not able to use them freely.

In earlier evidence sessions, public health witnesses described how e-cigarettes themselves are not safe or without risk. This is also likely to be the subject of further discussion, particularly given the recent publication of an independent review commissioned by Public Health England, which found that e-cigarettes are around 95% less harmful than tobacco. The Minister for Health and Social Services has been clear that this isn’t really the point however, and that the basis for bringing forward the legislation are the risks of normalising smoking behaviour, the possibility of e-cigarettes acting as a gateway to tobacco use, and the enforcement issue.

The independent review found no evidence so far that e-cigarettes are acting as a route into smoking for children or non-smokers, nor that e-cigarette use was having the effect of normalising smoking:

Since EC [electronic cigarettes] were introduced to the market, smoking prevalence among adults and youth has declined. Hence there is no evidence to date that EC are renormalising smoking, instead it’s possible that their presence has contributed to further declines in smoking, or denormalisation of smoking.

However, it’s widely recognised (including in the above report) that e-cigarettes are a relatively new product and further research is needed. The Chartered Institute of Environmental Health told the Committee:

it’s a cliché to say it but absence of evidence is not evidence of absence. I think we need to wait and see if e-cigarettes normalise smoking.

Waiting, according to the Minister, is too risky a strategy:

We won’t have definitive evidence for many years to come. What I don’t think we ought to be prepared to do as a committee or as a National Assembly is to take the risk that, in 10 years’ time, we will look back and say how much we wished we had acted then, before the harm had occurred.

It will be for the Committee to consider, based on the evidence it receives, whether the Government’s precautionary approach is a proportionate one.

Note:

As part of its evidence gathering, the Committee has invited individuals and organisations to submit their views on the proposals via a survey and written consultation, which have been running over the summer.

Oral evidence sessions will continue in September and October, and the Committee is expected to report on the general principles of the Public Health (Wales) Bill in November 2015.

Introducing the Public Health (Wales) Bill

8 June 2015

Article by Philippa Watkins, National Assembly for Wales Research Service

Today, 8 June 2015, the Welsh Government introduces its Public Health (Wales) Bill.

The Bill sets out a series of specific proposals in priority areas of public health policy. It aims to create social conditions that are conducive to good health and where avoidable harms can be prevented. According to the Explanatory Memorandum, the Bill’s preventative approach reflects prudent healthcare principles

by seeking to intervene at points with significant potential for long-term benefits, both for the health of individuals and in avoiding the longer term burdens caused by avoidable ill health.

What does the Bill do?

The Bill includes provision for the following:

Tobacco and nicotine products

  • Restricting the use of nicotine inhaling devices such as electronic cigarettes in enclosed and substantially enclosed public and work places, bringing the use of these devices into line with existing provisions on smoking.
  • Creating a national register of retailers of tobacco and nicotine products.
  • Adding to the offences which contribute to a Restricted Premises Order (RPO). (An RPO prohibits the sale of tobacco products from a premises).
  • Prohibiting the handing over of tobacco or nicotine products to people under the age of 18.

Special procedures

  • Creating a mandatory licensing scheme for practitioners and businesses carrying out ’special procedures’, namely acupuncture, body piercing, electrolysis and tattooing.
  • Introducing a ban on the intimate piercing of people under 16 years old.

Pharmaceutical services

  • Changing the way Health Boards make decisions about pharmaceutical services by making sure these are based on assessments of pharmaceutical need in their areas.

Provision of toilets

  • Requiring local authorities to prepare local toilets strategies for the provision of, and access to, toilets for public use, based on the needs of their communities.

What the Bill doesn’t include

Minimum unit pricing for alcohol, one of the more contentious proposals in the earlier White Paper consultation, is not included in the Public Health Bill. On 28 April 2015 the First Minister told the Assembly:

Whilst we believe that minimum unit alcohol pricing is a key public health measure, after careful consideration, we’ll not include a provision in the Public Health Bill whilst there is still some uncertainty about the timing of the European judgment on Scotland’s Alcohol (Minimum Pricing) (Scotland) Act 2012, but we do intend to publish a draft Bill relating to the minimum price of alcohol for public consultation in due course.

The lack of actions to tackle obesity was highlighted as a concern by some stakeholders responding to the White Paper. Proposals in this area were limited to setting nutritional standards for specified settings, namely pre-school and care home settings. The Royal College of Physicians commented:

we are very disappointed to see that this is the extent of the Welsh Government commitment in this white paper on measures to tackle obesity and physical inactivity in Wales.

The Welsh Government intends that the proposal to introduce nutritional standards will build on the work previously undertaken in schools and hospitals and will be achieved through secondary legislation and/or guidance. The Public Health Bill itself is therefore silent on tackling obesity and physical inactivity. The Welsh Government has stated that it continues to consider a range of actions to tackle obesity in Wales, ‘the majority of which do not require primary legislation or could be considered using existing legislative powers’.

Consultation

The Public Health Bill was introduced following an extensive period of consultation.

In 2012/13 a Green Paper sought views on whether a public health bill was needed in Wales, and the potential role of legislation in driving improvements in population health. There was particular support for the suggestion that health issues should be considered in all policy development.

On publishing a White Paper for consultation (spring 2014), the Welsh Government stated that this ‘health in all policies’ approach would be taken forward through the Well-being of Future Generations Bill, and that a Public Health Bill would focus on a set of practical actions in discrete areas of public health policy.

Responding to the White Paper, some stakeholders expressed disappointment at how limited the proposals for the Public Health Bill were, describing a loss of aspiration and a ‘significant step backwards from the more innovative high-level proposals contained in the preceding Green Paper’.

The Welsh Government has continued to emphasise that the Public Health Bill will focus on specific areas where legislation is an appropriate lever, and that this Bill will be complementary to the overarching approach taken forward in the Future Generations legislation. Whether the Well-being of Future Generations Act will satisfy the concerns of stakeholders may be open to question. The health sector have been critical that this legislation is nowhere near explicit enough in pushing the health agenda. Public Health Wales stated:

The [Future Generations] Bill has been drafted in a manner which fails to include health in the common aim and health in all policies is merely implicit. This means that there is every chance that despite two potentially impactful pieces of legislation that could set public health in Wales on a trajectory to be envied on the international stage, Wales could be left with no notable levers to make the strategic, large scale changes that are needed to address public health challenges.

The Public Health (Wales) Bill is expected to be referred to the Health and Social Care Committee for Stage 1 consideration of the general principles of the Bill.

Further articles on each of the Public Health Bill’s proposals will be published as part of a series throughout the week.

 

 

 

New Publication: Public Health White Paper: Listening to you – Your Health Matters – Research Note

15 October 2014

National Assembly for Wales Research Service

This note summarises the proposals and issues raised in the Public Health White Paper, Listening to you – Your Health Matters, and also some stakeholder reactions to these proposals.

Public Health White Paper – Research Note

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