Estimated reading time: 7 Minutes
01 May 2019
Much has changed in Wales in the twenty years since the first National Assembly for Wales was elected in May 1999. This is the third in a series of articles that attempts to describe some of that change. It has been prepared by Senedd Research as part of the Assembly’s activity to mark twenty years of devolution.
Sustainability of health and care services is a critical issue in Wales. Costs for delivering NHS services have continued to increase, and now account for over half (52.3%) of the Welsh Government’s total resource budget, compared with 39.8% in 2010-11. This increasing domination of the budget clearly impacts upon other services such as social care, while conversely, it is widely agreed that an under-resourced social care system puts further pressures on the NHS.
Experts have predicted that pressures on social care due to demography, chronic conditions and rising costs would require the social services budget to almost double by 2030/31 to match demand.
Wales has the largest proportion of older people per population in the UK, and many are living in rural communities and areas with high levels of deprivation.
Controversial comparisons are often made about the performance of the NHS in Wales versus England, but recent reviews have concluded that there is no significant difference in performance between the UK nations.
Since devolution, approaches to providing NHS services in the UK have become increasingly divergent. Wales has moved away from using an internal market to manage services; the role of the private sector in healthcare has diminished; and integrated Local Health Boards have been established. The Welsh Government’s ambition is to bring health and social care services together, so that seamless services are designed and delivered around the person, but there is a long way to go before this becomes a reality.
Our ageing population is well documented. When the Assembly was first established in 1999, 17% of the population was over 65; this rose to 21% in 2017, and is projected to reach 28% in the next 20 years.
Between 2015 and 2035, the proportion of all adults living with a limiting long term condition is projected to increase by 22%. The greatest increases are predicted to be in stroke (33%), heart conditions (31%) and neurological conditions including dementia (72%).
Average life expectancy today is 78 years for men and 82 years for women. However, men and women are likely to spend on average 17 and 20 years respectively living in poor health. The Welsh Government estimated back in 2006that by 2020, life expectancy would be 84 years for men and 87 years for women.
There are stark differences in life expectancy and healthy life expectancy across Wales which have not shifted in the past decade. Men and women in the most deprived areas spend about 19 and 18 fewer years in good health respectively, and die on average nine and seven years earlier, than those in the least deprived areas.
Average life expectancy has risen steadily since 1999, but progress has slowed considerably since 2011, with life expectancy increasing at a far slower rate than the preceding 20 years. This trend can be seen across much of western Europe, but in Wales the effect occurred earlier and now only Scotland has lower life expectancy (Wales has slipped from a rank of 16th to 24th in 25 western European countries).
The continuous decline in the mortality rate (number of deaths) in Wales has also faltered since around 2011. Mortality rates rose significantly in 2015, attributed at least in part to increases in deaths from flu, pneumonia, and dementia among those aged 75+. Public Health Wales Observatory has noted that current trends may mean that increases in mortality (like in 2015) could be more likely in the future.
Smoking, being overweight or obese, poor diet and physical inactivity are significant risk factors for numerous health conditions.
Smoking rates have fallen since legislation to ban smoking in enclosed public places was passed in 2007. Subsequent legislation (the Public Health (Wales) Act 2017) will introduce further restrictions on smoking in school grounds, playgrounds, and hospital grounds.
Rates of smoking have also declined for 11 to 16 year olds; from 13% in 1998 to around 4% in 2017/18. Whilst adult smoking rates have fallen consistently over the past decade, they have remained static for the past few years. A clear deprivation gap is also evident, with smoking rates in the most deprived areas (28%) over double those in the least deprived areas (13%). If current trends persist, the Welsh Government’s target of a reduction to 16% prevalence by 2020 will be missed by at least five years.
More mothers smoke during pregnancy here than in any other UK nation. A Public Health Wales project made recommendations for action on this issue in 2015 (but it is not clear whether they are being taken forward).
Adults are reportedly drinking less; the latest figures show that 18% of adults report drinking more than the recommended guidelines. While this represents a declining trend in self-reported drinking levels, there has been an increase in the burden of disease due to alcohol (by over a third) since 1990. No explanation has been given for this disparity as yet.
The Assembly recently passed the Public Health (Minimum Price for Alcohol) (Wales) Act 2018 which aims to reduce harmful levels of drinking by introducing a minimum price for the sale/supply of alcohol and making it an offence for alcohol to be sold below the minimum price. Time will tell what impact the legislation will have on alcohol consumption and the associated harms.
Weight and physical activity
Trends show that fruit and vegetable consumption has declined over time, while the prevalence of being overweight or obese has increased.
The latest figures show that 60% of adults are overweight or obese; 22% are obese. This has increased over time from 54% and 18% respectively in 2003/04. According to public health predictions, the continuation of current trends would result in two thirds of the adult population being overweight or obese by 2025.
A higher proportion of children are overweight or obese, and report unhealthy lifestyle behaviours, compared to other UK nations. The latest Child Measurement Programme shows that 26.4% of children aged four and five are overweight or obese compared to 22.4% in England and Scotland. The local authority area with the highest prevalence of childhood obesity (Merthyr Tydfil) is more than double that of the local authority area with the lowest prevalence (the Vale of Glamorgan).
The Public Health (Wales) Act 2017 was amended during scrutiny by the Assembly to include provisions on obesity. The Welsh Government is now required to publish a national strategy on preventing obesity and reducing obesity levels, and publish progress reports following reviews. The Welsh Government has since published a draft strategy, Healthy Weight, Healthy Wales for consultation. The draft strategy notes that habits relating to food consumption and physical inactivity have built up over decades, and says ‘societal changes have gradually designed physical activity out of our daily lives’.
Around half of adults get enough physical activity, and a third undertake no physical activity at all. One in six 11-16 year olds are achieving the Chief Medical Officer’s guidelines of 60 minutes of activity every day. A clear deprivation gap (17%) is also evident.
The Health, Social Care and Sport (HSCS) Committee recently published a report on physical activity of children and young people (which will soon be debated in Plenary). The Committee heard evidence that levels of physical activity and sedentariness among children in Wales are some of the poorest globally. Members concluded that ‘if we don’t start taking urgent action now to change attitudes towards physical activity, we are storing up problems for generations to come’.
Mental health and wellbeing
Recent years have seen a new emphasis being placed on wellbeing. The Assembly has passed two landmark pieces of legislation; the Social Services and Well-being (Wales) Act 2014, to reform and integrate social services law, and the Well-being of Future Generations (Wales) Act 2015, which identifies well-being goals for public authorities, aiming to improve the well-being of Wales both now and in the future.
The latest Office of National Statistics (ONS) report on wellbeing shows that while average levels of personal wellbeing did not differ much compared with the UK, a larger proportion of people reported ‘poor’ personal wellbeing ratings.
In 2018, a larger proportion of people (for the first time since 2012) reported low scores for all three positive measures of personal wellbeing compared with the rest of the UK.
There has been an increased focus on mental health within the Assembly over the past decade. Unique in the UK, the 2010 Mental Health (Wales) Measure (initiated by a backbench AM), aimed to facilitate earlier access to mental health services and improve care and treatment planning for patients.
Assembly committees have recently been shining a spotlight over mental health, putting increasing pressure on the Welsh Government to improve services. The Children, Young People and Education (CYPE) Committee is continuing to drive the agenda forward, following the publication of its 2018 Mind Over Matter report into the emotional and mental health of young people. The HSCS Committee’s subsequent report on suicide prevention endorsed CYPE’s recommendations and called on the Welsh Government to ensure mental health is given parity with physical health.
There are significant health and care challenges ahead for Wales. Clear gains can be seen over time in areas such as smoking, but causes for concern include the rising overweight and obesity levels, increases in chronic conditions, and mental ill health. The impact of health inequality gaps in key risk factors such as diet, physical inactivity and obesity could also be expected to increase in the future if they are not tackled with urgency.
The next article to be published tomorrow will look at education.
Article by Amy Clifton, Senedd Research, National Assembly for Wales