Transcript
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Speaker: Croeso, welcome to The Exchange, the official podcast of Audit Wales. This episode is about prevention. As defined by the Wellbeing of Future Generations Act, the prevention principle requires devolved public bodies to consider how to prevent social problems from occurring or getting worse.
Speaker: I began by speaking to Katrin Holsinger about what prevention means in practice and why Audit Wales has chosen to focus on prevention in our No Time to Lose report. Thanks, Alex. So on one level, ah prevention is common sense, isn't it? We all know that stopping a problem from happening in the first place is better than trying to fix it later. It's that old adage of prevention being better than cure, whether it's keeping people safe and well, giving children the best start in life or not putting carbon in the atmosphere.
Speaker: But in the complicated world that we live in, it isn't quite so simple. And prevention is a spectrum. And it's going to relate differently in different public sector and public service contexts. So obviously, the Wellbeing Future Generations Act defines prevention for us as preventing problems from occurring or stopping them from getting worse. ah But there are also other more specific definitions of prevention. And the Future Generations Commissioner has agreed one with the Welsh Government.
Speaker: And it creates four separate categories, ranging from primary prevention, ah which is about creating resilience, so more focused on those building blocks of health, through to secondary, which is about targeting action where there's a high risk ah of a problem occurring. Then tertiary, which is about stopping a problem from getting worse, through to acute, which is really about managing a negative situation. tertiary,
Speaker: This might sound a bit esoteric, but it's actually very practical. And having a definition like this can help with planning activity, allocating resources and seeing what's working.
Speaker: And why would you say prevention is an important principle? Well, the report we published just last year, No Time to Lose, set out how certain demand pressures have increased in the 10 years since the Act um came into place. um So, for example, things like spending on cancer, which has increased by 40%, in real terms over over that time. Spending on looked after children has increased by over 70% in real terms in that time. We've seen dramatic rises in things like the number of people living in temporary accommodation. And then when we look at the natural environment, we can see things like an estimated one in six species being at risk of extinction in Wales. So, you know, massive demand pressures and and public bodies won't be able to build a sustainable public service model without getting ahead of that um tide of of demand.
Speaker: So the value of prevention is well established. and There's lots of evidence out there that quantifies the impacts um of different preventative interventions, both for individuals, for the public purse, for the wider economy.
Speaker: So things like public health, for example, is said to offer a £14 return for every £1 invested. and Programs promoting breastfeeding can save the and NHS around £50 million annually by improving mental health and reducing hospital admissions. and Data sharing, for example, between emergency departments and the police can provide returns of £82 for every pound invested and substantially reduce costs associated with violence. And there are many more examples of these kind of returns on investment.
Speaker: So we know that it makes sense. There's lots of evidence out there, but public services face enormous immediate pressures. So notably in the and NHS, where planned care waiting lists grew by over 50% between 2020 and 2022 to nearly 700,000. So that requires that sustained focus um of resources on that immediate issue.
Speaker: And increases in health spending have been significant. directed towards secondary care as as you might expect in the context of those challenges. So that spending on secondary care grew by 39% in real terms um over that that kind of 10-year period.
Speaker: However, real-term spending on primary care has remained relatively stable and that's in the context of primary care having a really important role to play in preventative healthcare.
Speaker: But at the same time, the contribution that the NHS itself makes the population health outcomes is comparatively small. you know Many of the levers sit with other public bodies, especially with local government. And pressures on council budgets and demand for statutory services has impacted spending on the preventative services that councils provide, things in the regulatory space as well.
Speaker: So things like community safety, which can make important contributions to those building blocks of of health, have seen significant reductions and in spending over the last decade. Thank you. And why would you say prevention isn't happening at the level we'd like to see in Wales?
Speaker: Well, I'm sure there are lots of reasons for that ah that relate to all sorts of different challenges that public bodies face, but just a few that kind of um come to... come to the to mind. So and on the one hand, you know, we understand the the benefit and the value of prevention. you know, public bodies have also got a duty in Wales to balance the immediate pressures with longer term impacts through the Wellbeing of Future Generations Act. um We know that prevention can deliver better outcomes. It can deliver better value for money. We also know that the current situation with these increasing demand pressures and diminishing budgets is unsustainable. But at the same time, the need to invest limited resources to meet those um immediate demand pressures creates really difficult choices. and Whilst we might have
Speaker: evidence on likely returns on investment, it takes time to see those returns on investment. And those returns may be accrued by different bodies across different parts of the public service system, ah not ah necessarily the organization that is making um that investment. And then there are public expectations about the access to and quality of services in the here and now, all of which make it really difficult for public bodies to think about where they put their resources.
Speaker: And why are Audit Wales centring prevention in their discussion of the Act? No Time to Lose states that accelerating progress under the Act starts with prioritising prevention. And that is because of this cycle that public bodies find themselves in with increasing demand pressures, increasing complexity of that demand ah and increasing pressure on resources. and Without a more fundamental shift to prevention, budgets will be exhausted and outcomes will likely be worse. So how do we break that cycle? It really has to be a fundamental test of application of of the Act itself.
Speaker: How can public services gauge whether preventative measures are effective? Taking a step back from prevention and for a moment, what we see often in our work, but beyond prevention specifically, is that public bodies are often not able to demonstrate the impact of various plans or activities or the value for money that those things are achieving. And we reported some of this in in No Time to Lose, but actually it comes across in ah many of our pieces of work.
Speaker: and So, in no time, Toulouse, we pointed specifically to some work that we'd done in councils that found that lack of there was a lack of focus on measuring outcomes and that their performance reports tended to focus on outputs, the what, with little evaluation of their so what. Our work on active travel is another example where we found that government um didn't have robust long-term data on how and why people people travel and on the wider outcomes from active travel. And there are a few other examples that we touch on in No Time to Lose. um
Speaker: Measuring the impact of prevention ah is is really important if public bodies are going to build a case for shifting or increasing investment, but it's notoriously difficult.
Speaker: and It's helpful actually to go back to that definition of prevention here because it's likely to be and very difficult to measure the preventative impact of um those ah primary interventions that are designed to improve the building blocks of health and and create resilience, not least because those benefits will likely accrue over a very long period of time and across different different public bodies.
Speaker: We also make a point in No Time to Lose that sometimes targets are not helpful in promoting prevention and longer term planning. So for example, um we point to Welsh Government's 20,000 homes target. We've reported that the five-year target period approach risks embedding a sort of unsustainable delivery model where you The pattern is delivery is lower earlier in the period and then ramped up later. um Looking at the the health service, as the future generations commissioner has reported, and based on the views of of health boards, is that Welsh Government's wider performance and assurance demands reinforce the short-term focus and that the metrics and enabling actions set out in the in the framework need to better align with prevention.
Speaker: OK, thank you. And how can the Welsh public sector grow and improve its prevention work? We made four recommendations in No Time to Lose. These recommendations weren't to individual public bodies because we've made recommendations through the examinations over the five years' worth of work that led up to No Time to Lose. made recommendations to those individual bodies. Our recommendations in this report were strategic in nature and they were directed towards the Welsh Government, focused on what it can do to create the conditions for change and further progress under the Act. Our first relates to post-legislative evaluation.
Speaker: Things have changed since the Act came in came into being. There are new duties, new partnerships and changes in performance regimes. And we think that post-legislative evaluation is you know inherently a good thing given the broad ranging nature of this legislation and the um the ambitious nature of it. We then ah made a recommendation relating to minimising funding uncertainty. We recognise that Welsh Government faces its own constraints in this regard, but inevitably it's something that comes up throughout our work that public bodies um report on a frequent um basis as something that impedes their own planning. And the recommendation is not just about short-term funding cycles, but also about the timing of notifications about ring-fenced in-year funding, about capital that's not backed up with revenue. So our focus is really on, whilst this is a difficult nut to crack, Welsh Government working with public bodies to explore what is possible and any opportunities um to minimise uncertainties in a way that supports bodies' medium and longer-term planning. And that obviously relates to prevention because um often prevention requires that sustained investment commitment. Our third recommendation was explicitly on prevention. The commissioner recommended that the Welsh Government ring fences funding for prevention, which increases over time. And this reflects calls from several organisations a UK level. We recommended that the Welsh Government also explores other complementary ways of encouraging investment in prevention. So we think there's more that could be done on the mechanisms that help to drive that change. Firstly, understanding the levels of investment in prevention and finding a model for doing that, potentially drawing on and learning from the work that SIPFA does. have done in that space, exploring ways to embed prevention in the budget process, working with public bodies to understand how investment in prevention can be incentivized at a local level, which may be about protecting pots of money or it may be about freeing up pots of money. And then, of course, learning from others, because actually this is very, very difficult stuff. So this is in in nature quite an exploratory recommendation. ah that is designed to develop some tools and mechanisms that can promote and support further investment in prevention. And then our final recommendation was about taking a fresh look at the assessment of performance under the Act. So we think there's an opportunity to to revisit how that's done under the Wellbeing Future Generations Act and specifically to understand um the impact public bodies are having and what that means across Wales and for the national indicators. At the moment, there's not really any, well, there isn't a requirement on public bodies to um think about their own performance measures in light ah of the national indicators. it's A bit of a disconnect there between what we're measuring in terms of the well-being of Wales potentially and and how that translates at a local level.
Speaker: And then there's um the the wider issue of the assessment of performance and how that can promote the aims of the Act, specifically prevention, but also collaboration, going back to what I was saying a moment ago um about some of those um targets and measures, um which may be unhelpful in furthering the aims of the legislation.
Speaker: Thanks, Catherine. Following this, let's look at some examples of prevention in practice. Mary Wilson from Public Health Wales runs a programme called Design to Smile, an effort to foster good oral health among children through an early intervention approach. so Design to Smile is the national child oral health improvement programme in Wales. Its aims are to prevent tooth decay and to reduce dental health inequalities in children living in Wales. So it's a national programme. It's Well defined by the Welsh Government in Welsh Health Circulars and it's delivered by Wales in the community dental service teams within local health boards. And so the programme's a huge team effort and and we need to acknowledge all those involved in the programme for their commitment and determination since 2008 to improve childhood oral health.
Speaker: In what ways has Design To Smile helped to improve dental health and hygiene? Design to Smile follows a marmot approach of proportionate universalism. So it's aiming to reduce health inequalities whilst improving health for all. And it is based on approaches that are recommended by NICE guidance. And so we measure our outcomes. activity on an annual basis and numbers I can give you today are for example last academic year we delivered oral health training to just under 2,000 professionals including health visitors, childcare students, health and social care professionals. Another 165,000 tooth brushing home packs were distributed via the nurseries and schools to those children participating and then we also had
Speaker: 677 primary schools schools facilitating the fluoride varnish application visits from Design to Smell professionals. Our numbers are huge and show the scope and breadth of work that is delivered as activity within the programme.
Speaker: In what ways is an approach that targets children helpful in preventing potential future dental issues? Yes, so we know that childhood oral health is a risk predictor of the oral health you'll have as an adult because unlike the rest of your body, and once you start getting your adult teeth come through into your mouth from about the age of five and six, they are the only natural teeth you'll have for life. Teeth do not regenerate in a way that other cells in your body, for example your skin, can do. And so we've got to protect them from early childhood so that they can last you a whole lifetime. The programme is trying to ensure that children know and can implement the best ways to keep their teeth healthy.
Speaker: And by doing that from early childhood, we know that it is an costef effective way to ensure that the money spent during childhood to protect those teeth is much less than the amount of money required to and treat and replace teeth.
Speaker: What have been the main outcomes from Design to Smile and what are you looking to improve on? So we have a robust national dental epidemiology program which obeys the bays did and teeth of children in Wales and so we can monitor the prevalence dental disease across the years.
Speaker: so As I said at the beginning, Design to Smile was initiated in 2008 when it was seen that 48% five-year-olds were affected with tooth decay. And the latest dental epidemiology survey from 2022-23 showed that 32.4% five-year-olds had experienced tooth decay. So gone two children in three children.
Speaker: and twenty two twenty three showed that thirty two point four per cent is fiveyearolds had experienced tooth decay so it's gone from one in two children to one in three And obviously we're working to reduce dental health inequalities, so the dental epidemiology surveys and measured that across Wales as well. Children living in more deprived areas can be twice as likely to have tooth decay and have three times as many teeth affected.
Speaker: So Design to Smile targets those areas in order to reduce those health inequalities. Can the principles and learning methods from Design to Smile be applied to other forms of preventative work?
Speaker: So the structure and intervention delivered within Design to Smile is quite specific to dental health and how to prevent dental disease. However, we follow the principles of my Sir Michael Marmot in terms of proportionate universalism and those are transferable to other health promotion agencies. where the aim is to improve health equity. We work very closely with health visiting profession and educational settings. And so that close partnership working is is something that other health of initiatives try to also, making
Speaker: you know, dental health and and other health conditions are priority for all can allow us to reach families and children in in different ways and improves access and inclusion to our interventions. So that would be relevant for a lot of health promotion initiatives.
Speaker: Thanks, Mary. Looking at another practical example of prevention, David Llewellyn from the RSPCA spoke to me about nature prescriptions, a form of social prescribing intended to improve people's mental health by connecting them with nature.
Speaker: There's a lot of evidence out there now that if we connect with nature or if we are active in nature, that can really support our health and well-being. And um what ah RSPB prescriptions are is a very simple way in which healthcare care or other professionals can encourage and support people to connect to nature, get more active in nature, such that their health and well-being benefits.
Speaker: Okay, can you ah give our listeners an idea of what a nature prescription might typically involve or look like? Okay, so I should imagine perhaps that a lot of your listeners will be familiar with the concept of social prescribing and green social prescribing, where, for example, somebody goes to GP or maybe a community connector and then they are signposted towards an activity in nature. And that's really, really great. You know, that should be encouraged because that's obviously beneficial for people in terms of their health and well-being.
Speaker: What an ah RSPB prescription is, is something that really adds value to that and complements it in that um we provide a booklet which has suggestions or ideas for how people can connect to nature where they actually live rather than getting signposted to an activity.
Speaker: um And there's just a conversation between that healthcare care professional and the um the patient or client saying to them, this can really benefit your health and well-being.
Speaker: Here's a booklet which has suggestions and it's in the form of a calendar. So they're very nice suggestions which go right throughout the year and take into account the changes in the seasons and go away and and try them. And they are things that, as I say, they can do on their own doorsteps. They can do in local green spaces. They can do in a local park.
Speaker: And we also encourage them, if they wish, to go a little further afield as well. But they don't have to go to an activity that they are sent to or, an you know, they can do things, as I say, within their own local environment. And that gets around a lot of the barriers and challenges of green social prescriptions. So that's why it adds value to it and and complements it as well.
Speaker: And ah how do nature prescriptions help to improve the well-being of people who take part in the programme? Okay, so if you're given a nature prescription, what we hope is that ah that person then will be encouraged by by the person who was given to them in the first place. to do the prompts and suggestions and they're very very simple that could be for example just going to a local park and listening to birdsong or taking notice of what's around you in terms of even looking at sunsets or the skies cloud formations and as i say the evidence is to to suggest that it really improves people's mental well-being and it can encourage them to be far more physically active as well so the
Speaker: It has a huge impact on how people feel about themselves and supporting their general health and wellbeing. What examples can you provide of this? In Cardiff where we've produced one of our first um nature prescriptions, in fact the first one in Wales along with Newport, I spoke to a surgery last week and they were telling me that a gentleman who has been largely housebound for quite a while had to come along for a flu jab And he actually walked to the the surgery. He'd been a recipient of ah one of the nature prescriptions. He was really enthused by it. And ah he actually walked along the Taft Trail deliberately so he could take in the nature on the way to coming in in for his flu job. And and that was almost, ah you know, they'd had difficulties in getting him to come in. previously because of him not feeling in a good place about walking and getting out and being active. So there's a good example in a practical sense i always worked with for one individual.
Speaker: Thank you. In that sense then what would you say the value is of connecting with nature in a health context? Okay so this if you look at some of the evidences out there we know now that um For example, that if people spend about 10, maybe 20 minutes outside listening to birdsong, for example, that's something very, very simple. We know that King's College London produced a study a couple of years ago showing that their levels of anxiety um dropped quite significantly. and that those impacts lasted for about five to six hours. So it just shows that that that's one example that it can be hugely beneficial for people struggling with their mental health. We also know, though, it can encourage, as I say, people to be far more physically active. It's not saying you've got to go from couch to 5K straight away. That might be something people want to do, of course. But um for people who are um you know struggling with mobility or something, just getting them gently active outdoors can be of huge benefit to them. and what results have you seen from your work, um especially in terms of preventing long term problems that might arise from physical or mental health issues? When the RSPB did some trials back in Edinburgh, they showed that about 75% of people who received a nature prescription really felt it benefited them.
Speaker: And over 90% of GPs who who gave out the nature prescriptions said that they would continue to do so. So they obviously realise, both the recipients and the people who have been providing them, that it can have a major impact on people's general health and well-being. And and and that's so important. You don't have to have, you know, some specific diagnosis to get one of these. It's just if that healthcare professional feels that, you know, you would benefit from supporting your mental health and physical health in a more general way, then that's what the prescriptions are for. And hopefully, in terms of a preventative approach, what that means is that those people become far more active every day, their mental health improves, their physical health, they become more active.
Speaker: And hopefully that then has the impact that they are less likely to come into the surgery. Nature prescriptions have been launched in multiple areas of England, Scotland and Wales. Do the results from area to area differ based on local context?
Speaker: Hopefully not, because really what we are encouraging people to do is to take advantage of the nature and environment that's on their own doorsteps. So, for example, if you think about it, If one area were more rich, should we say, in having nature reserves or parks or or what have you on their doorsteps, you you might think that people would be perhaps um finding the benefits more as ah as a result of going out and connecting with nature there. But because the prescriptions are very much about how people can access... nature in their own gardens, little green spaces, even just by opening the window somewhat, what we would hope to see is that wherever the prescriptions are, then you should benefit people in a rather equitable way. And and that's really important in terms of getting around some of the sort of health ah in in inequities and inequalities in terms of access to green space, perhaps. What more could public services in Wales be doing to improve people's access to nature and how might that benefit people's mental and physical health in the long term? Okay, so obviously what we'd like to do, as I say, right at the very start, you know there's a lot of robust evidence now ah out there which shows in the literature and from the practical sort of feedback that we we've got from from from these things being put into practice that that that that this works. So...
Speaker: We've got you know big problems here in in Wales and the UK in terms of the pressure on our and NHS. you know A lot of people struggling with mental health, struggling from you know maybe conditions that are associated with you know sedentary lifestyles or even ageing, for example. so um What we would hope is that nature prescriptions are a way on one way. And what I would say, and I haven't said this, is these are not a panacea, of course. It's not either or. Nobody should come in and give one of the nature prescriptions in exclusion to anything else that...
Speaker: that person, the GP or community connector feels would benefit them is something additional in the armory. So what we would hope is that um people become more active in nature. They benefit as a result of that in terms of their mental and physical health.
Speaker: And that hopefully will first and foremost support that person. But secondly, reduce pressures on an already stretched and ah NHS as well. And in terms of access, what we need to do, I think in terms of public bodies, is to make sure that we do have equitable access to green space, even with our urban areas. I think nature's rather overlooked in terms of what it can do, in terms of the benefits,
Speaker: not just by connecting in this and instance, for example, but through air quality, for example, we're in a climate crisis as well. So we need to make ensure that all our areas are as nature rich as they can be, whether you live in an inner city or whether you live in one of our more rural areas here in Wales.
Speaker: Thank you. What would you say are the main challenges you faced in your work? I think obviously one one of the things is we spend a lot of time talking to healthcare and other professionals. um So from ah ah the point of view of maybe some some healthcare professionals, they are not aware of what the benefits can be to people by connecting meaningfully to nature. So we need to persuade them of what those benefits are.
Speaker: And of course, what we ensure is that GPs, for example, we know are hugely pressed for time. So this is where the nature prescriptions can be of a real benefit. They don't have to know what's out there in terms of services or activities, etc. They can just simply have a very brief conversation to say to this person, the evidence suggests it will work for you.
Speaker: Please go in and try it. So it's about getting around maybe some degree of scepticism amongst some health professionals about a lack of knowledge as well. I think some of the other challenges are that, as within a lot of social prescribing backgrounds and and so on, is funding. We are lucky. We are funded through the People's Postcode Lottery. The players of that have provided the funds for us to do this free in Wales. So that's great for now.
Speaker: But um we need to be looking at um other approaches to preventative health and and hopefully they'll be cost effective. But that argument is always quite difficult to make. But that's the way that we should be going because we need to reduce stresses and strains on our already stretched and NHS. So we feel this is a good addition to how people can have a preventative approach to health and well-being.
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Speaker: For more information, check out the show notes. You'll find all the relevant links and contact details there. You can also visit our website at audit.wales. If you have any questions or thoughts, we'd love to hear from you.
