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Sophie Howe is Future Generations Commissioner for Wales, overseeing the implementation of the Well-being of Future Generations (Wales) Act. We spoke about what the legislation has achieved so far, and what advice she has for other countries now considering similar approaches. 

What do health inequalities look like in Wales?

As with the rest of the UK, it depends on where you live in Wales. Areas like the South Wales Valleys are still experiencing the lasting effects of the mines closing in the 80s, with generations of families who have been out of work. There are significant differences in health between the different regions of Wales, and even within neighbouring areas, and that’s something we’re really working to change. In Cardiff for example, there’s about 10 years’ difference in life expectancy depending on whether you live in the more affluent leafy suburbs of north Cardiff, or in the south of the city. 

How is the Future Generations Act working to change this? 

The Act applies to all 44 public bodies in Wales, giving them a statutory duty to take decisions in a way that takes into account the needs of future generations in Wales. 

Public bodies must work towards seven ‘well-being goals’. These include things like a healthier Wales, a more equal Wales, building skills and jobs, and creating an innovative, productive and low carbon society. They also have to demonstrate that they're applying specific ways of working, including planning for the long-term, taking preventative action, collaborating with each other and with citizens, and integrating their thinking.

Essentially, we’re trying to create attractive, viable, safe, well-connected communities in Wales, by addressing the wider determinants of health. What’s so important about the Act is that it places the responsibility for this on all of our public bodies, rather than just in the hands of the NHS. That’s more realistic as it is estimated that between 80-85% of what’s important in tackling health inequalities sits completely outside the control of the NHS: things like how we plan and design our communities, whether people have access to decent jobs, the quality of people’s social connections and relationships. 

How has the Act started to see results? 

As part of the legislation, public services boards have been set up in each local authority to bring the key partners and delivery agencies together: the health board, the local authority, fire and rescue service, Natural Resources Wales, representatives of the third sector, the police service, and sometimes local colleges or universities. Collectively, they have to undertake a ‘well-being assessment’ for their area (considering health, social, economic, environmental and cultural issues). And they then set a plan for how they're going to work together to improve wellbeing and address the issues they’ve identified. 

Those mechanisms are starting to make some real differences. In Cardiff, the public services board has had a focus on poor air quality in the city, recognising the environmental and health impacts. We’re now seeing a mass rollout of the bikes on hire scheme, and millions of pounds of investment to support cycling in the city. The council has recently proposed a congestion charge, and every public body in the Cardiff area has signed up to a healthy travel charter – that means encouraging around 55,000 staff to consider greener, healthier ways to travel. GPs across Cardiff are now also prescribing free access to the bikes on hire for people who could really benefit from that activity.

That’s the sort of difference you see when you create statutory duties for people to collaborate and integrate their thinking, with a focus on the broader things that we're trying to achieve for our community. 

There are plenty of other examples. Tackling adverse childhood experiences (ACEs) has emerged as a focus for most of the public service boards, which is really important in terms of addressing long-term health and societal outcomes. This is leading to a more trauma-informed approach to policing, with 5,000 police officers across Wales now trained to identify childhood adversities, and work going on with partners to provide early interventions for children.

It’s these sorts of things, which are happening at scale across Wales, that are being driven by the Future Generations Act.

What barriers have you faced and how have you overcome them? 

I always say it’s not just a journey we’re on, it’s a full-on expedition. The main challenge has always been trying to get people to actively apply the legislation rather than just comply with it. There are still those that think as long as they mention ‘sustainable development’ in their strategy they’ve ticked the box, but overall I think the tide is turning. 

In my early years as commissioner I focused on identifying the ‘frustrated champions’: the people who’ve always known there was a better way of doing things, and have been frustrated by how the system works. They’ve been able to embrace the Act as a framework that gives them permission to challenge the system. Those people are incredibly powerful, and there are more of them emerging all the time. 

I also recognise the power of young people’s voices to call out our current decision makers. We've been working closely with young climate strikers in Wales, and we’re also putting a group of young leaders through an intense development programme. This will involve a reverse mentoring scheme, where existing public body chief executives will be mentored by these young leaders. 

What are you going to be focusing on over the coming year? 

My current focus is on scrutinising the draft Welsh government budget. I monitor spend in different areas, we’ve done a lot of work to define what counts as ‘preventative spend’ for example, so that we can chart progress over time. 

I’ve challenged the government significantly in terms of their commitment to decarbonisation. As a result we’ve seen a 28% increase in spend on decarbonisation in this year's budget. Okay, we’re starting from a relatively low base, but that’s really quite significant. 

This year we’ll review procurement practices in Wales. Our public services spend about £6bn pounds a year procuring goods and services, and I want to see how that's supporting our well-being goals and what more could be done. 

I'm also considering a review into how the performance framework for health services either helps or hinders them to make progress on their obligations under the Act. And I want to make sure that the health service’s transformation fund is applied in a way that is genuinely transformative, through the lens of long-term prevention.

What advice would you give other countries considering similar approaches?

One thing to bear in mind is how any new act will relate to the plethora of other inspectorates and pieces of legislation that already exist. There needs to be a plan for unpicking all of that and making sure that whatever is introduced is effective as a central organising principle among everything that country does, rather than just an add on. 

And having some kind of independent commissioner is absolutely crucial. Because otherwise it's all words and not enough accountability. In Wales I think my powers could be strengthened further. Currently I’m able to name and shame, and so far that’s been reasonably successful. But I often think about the penalties in place for breaches of information around data protection (under GDPR), which are really harsh. Compare that to what happens currently if an organisation takes decisions that are clearly going to have an adverse impact on future generations or particular sections of society. The penalties aren't there. 

Even so, just having someone able to call out decisions and speak up on behalf of future generations is really powerful. 

This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.

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