At this point in time, the UK has not fully entered a Covid-19 recovery phase and the consequences of Brexit are being worked through. It is important to acknowledge that some indicators and research show disruptions, due to Covid-19 especially, which makes planning at a time of uncertainty particularly challenging. We will review our analyses to ensure they reflects current and future trends as and when new or more reliable information becomes available.

Good health is critical to overall personal well-being and can have a direct impact on the wide well-being of individuals and communities. Human health depends on healthy environments and ecosystem services. Unfortunately, health and well-being in North Wales are not showing a wholly positive trajectory. The main factors that contribute to poor health and wellbeing are deteriorating rather than improving and social and health care use is increasing not decreasing.[1]

Overall, the root cause of well-being inequality appears to be poverty. Specifically, its associated relationship with factors such as very poor health, being disabled, workless, having no or only a basic education, being single, separated, widowed or divorced, renting or being middle aged. People living in the most deprived areas not only have a shorter lifespan, but also spend less of it in good health. Despite overall increases in life expectancy, the gap between the proportion of life expected to be spent in good health in the most and least deprive areas has shown no clear sign of reducing in the last 10 years.

People in persistent poverty are at particular risk of having poor physical and mental health; and children, especially, are at an increased risk of mental health problems, obesity and long standing illness. The poor diet of people in poverty is largely the result of socio-economic disadvantage, not poor choices.  Poverty is one factor that can lead to the poor health and unhealthy choices of those living in the most deprived areas as they have a limited range of options available to them due to low incomes and the stress associated with poor conditions.

There are significant health inequalities affecting the lives of people living in Conwy County Borough and Denbighshire. The wider determinants of health such as housing (in terms of quality and supply), education, employment and environment may contribute to less healthy lives.[2]   Health impacting behaviours such as smoking, drinking/substance misuse, poor diet, and a lack of physical activity are also influenced by mental well-being, which can be low if these determinants are poor.

Whilst the long term resilience of groups with poorer personal well-being and less favourable outcomes is currently unclear, without intervention, some small communities are likely to continue living with factors associated with deep rooted deprivation.

The effects of the Covid-19 pandemic have not affected everyone equally, and have, in particular, resulted in significant impacts for people’s physical and mental health, and well-being more generally. Those over 65 years old have been particularly affected, as have males, people from ethnic minorities and those from deprived backgrounds.[3] Worsening mental health is more likely to be seen in those most affected by the virus. This is a particular concern for certain groups, including young people, people from low-income urban households and Black, Asian and minority ethnic groups, who may be more likely to live in overcrowded homes and poor quality-environments, and to lack access to green spaces.

As a result of Covid-19 we have seen inequalities exacerbated (with people with disabilities or from Black, Asian and minority ethnic groups being more likely to die from Covid-19) and these health inequalities are likely to continue for the medium and long term. The prevalence of ‘long Covid’, the term used to describe continued symptoms of Covid-19, is likely to compound existing inequalities in the same way Covid-19 has.

We will need to review our preparedness for future pandemics. As a result of Covid-19, we have learnt a great deal about the demand and capacity shortfall in our hospitals and wider health and care services (see our ‘emerging threats to health and well-being’ topic for more information). There is a clear need to have sustainable services that can respond to increases in demand for care and referrals into the health and care system. This must be done in a way that supports people to access the right level of services, which may be different from those that have been offered traditionally in the past. We have learnt that we can do things differently and we must build on the innovation and change that has benefitted us during the pandemic. There is also wider learning associated with the changes that responses to Covid-19 brought about. For example, digital health services or changes in support for homeless people, a pivot to online working etc.

Healthy start in life

It is in the early years of a child’s life that we lay the building blocks for health, well-being, learning and relationships for the future. When children have a protective, safe, secure and loving environment to grow up in they can flourish and thrive. From pregnancy and through childhood children benefit from a positive and stable home, with healthy and supportive relationships that enable them to become healthy and happy adults.

There is a strong body of evidence of the importance of the first 1,000 days of a child’s life; addressing inequalities and intervening early to prevent health problems can help people make the best health choices for themselves now and for their children in the future. The association between adverse childhood experiences (ACEs) and poor outcomes in adulthood is well-understood, and these outcomes (poorer mental health, lifestyle choices that affect health and well-being) can be drivers for lower than average well-being.

There is also a strong economic case for investing in the early years of life. The rate of economic return on investment is significantly higher in the pre-school stage than at any other stage of the education system. Despite this, investment in services for children and young people is often at its lowest in the very early years which are the most crucial in the development of the brain. Investment only increases at the point when development slows.

We know that a healthy start in life can affect a person’s long-term health for this reason high incidences of low birth weight, which are seen in some of the more deprived areas of the two local authority areas are of concern. Teenage pregnancy, where we have seen an improving trend remains of concern because of the link with poorer health outcomes for both mother and baby.

We know that a person’s physical environment plays a key role; with poor health associated with homelessness, poor quality accommodation and fuel poverty. By the same token poverty, unemployment and personal safety, all affect a person’s physical and mental health.

From childhood and throughout adulthood, life style factors also play a key role in determining health, such as smoking, diet, physical activity and alcohol consumption. There is some evidence of concentrations of particular poor life expectancy outcomes among certain geographical communities and among people from particular backgrounds or with particular characteristics although further work is required to develop a firmer understanding. Further information can be found in the North Wales Public Health Directory and in the topic pages of this site.

Health and health equality

Advances in health and living conditions are helping people live longer. There are advantages to increases in longevity that improve not just the quality of life of the individual but also of the wider community. However, a rise in the elderly population, particularly if not matched by health and social improvements, will place ever-greater pressure on the public finances, as a relatively smaller working-age population supports growing spending on health, social care and pensions. In order to ensure we live in good places to grow old, the public sector has to consider the provision of good housing, an environment where older people are valued and respected, and a place where people are not isolated or lonely and have the support they need to enhance their health and well-being.

These challenges can exacerbate the use of natural resources and increase pressure on ecosystem goods and services. The move towards health prevention to ease the burden on the NHS and associated services provides amplified opportunity for increasing the resilience of ecosystems and human health.

Systems need to adapt to an ageing population. As the “Inequality in a Future Wales” report states:[4] ‘A ‘care-led recovery’ puts childcare and the care needs of older people on an equal footing with ‘green jobs’ in benefitting health, the environment and the economy.”

Both Conwy and Denbighshire have large populations over the age of 65 with population projections suggesting substantial and continued growth in the number of older people and the percentage of older people in the population of each county. That people are living longer is a positive trend. However, increasing numbers of older people is likely to lead to an increasing number of people experiencing age related problems such as, chronic physical and sensory diseases, dementia and falls. As people live longer, they are likely to be providing unpaid care for longer. Improved life expectancies also mean that people with complex needs are living longer than ever before, which is a something to celebrate as a success of improvements in health and social care. We do however, need to make sure that health and social care services are able to support this increase in demand as well as provide support for unpaid carers.

There is health inequality within the area. The health domain of WIMD measures lack of good health. Of all the WIMD domains, the highest number of areas in Rhyl in the 10% most deprived areas was in this domain; clearly demonstrating the relationship between socio-economic disadvantage and health and well-being.[5]

People living in the areas in the most deprived fifth of Conwy County Borough or Denbighshire not only have a shorter lifespan, but also spend less of it in good health compared to those living in the least deprived fifth. There is a difference of 12 years of healthy life expectancy for males in Denbighshire’s most deprived areas when compared to the least deprived (the widest gap for the whole of Wales), and 6.5 years for women. The gap for men in Conwy is 6.9 years and 5.2 for women.[6] Despite overall increases in life expectancy, the gap between the proportion of life expected to be spent in good health in the most and least deprive areas has shown no clear sign of reducing in the last 10 years. Positively though, smoking and alcohol use is a reducing trend.

The long term upward trend in the proportion of people who are overweight or obese is also associated with a rise in chronic health problems that could impact on healthy life expectancies in the future.

Evidence shows that low-income areas suffer not only from issues associated with poor housing, lower educational attainment and poor diet, but also less access to good quality green and blue space, all of which contribute to poor health.

Climate change emergency and healthy places

Human health depends on healthy environments and ecosystem services. They include food and fresh water; regulation of climate, floods and disease; opportunities for physical activity; for living, learning, working and playing and for aesthetic and cultural enrichment.

Public Health Wales in their recent research on Rising to the Triple Challenge of Brexit, COVID-19 and Climate Change for health, well-being and equity in Wales, found that climate change can have direct and indirect impacts on health in Wales, through impacts such as air pollution on respiratory disease and extreme heat event causing excess heat related deaths and through behaviours for example, diet, nutrition, active travel and alcohol.[7]

Wales cannot work towards healthy places for people without resilient ecosystems and cannot make our ecosystems resilient without safeguarding stocks of natural resources. The potential impact of climate change and extreme weather events on public health can be negative. For example, people who experience flooding in their homes and local communities may experience lower subjective well-being and increased anxiety. Flooding can cause death, illness, injury and stress, with impacts possibly far greater for more socially vulnerable communities.

23% of deaths globally are estimated to be due to modifiable environmental factors. Air pollution is the top environmental risk to human health in the UK, and the fourth greatest threat to public health after cancer, heart disease and obesity.[8]

There is still more to do to make sure that there are healthy places for people, protected from environmental risk across the areas (see our summary on the ‘globally responsible’ well-being goal for more information).

This continues to result in substantial impacts on human health including the significant flood events in 2019 and 2020 and rising temperatures exacerbating urban heat island effects. Global warming of more than 1.5oC above pre-industrial levels will undermine life support systems for humanity. If the world warms by 2oC one in 20 species will be threatened with extinction (Intergovernmental Panel on Climate Change, 2018).

Healthy housing

Housing conditions affect people’s health and energy use. Eighteen percent of homes in Wales pose an unacceptable risk to health, and 12% of households are in fuel poverty. Damp and mouldy homes increase respiratory problems by between 30% and 50%, especially in children.[9]

Investing in energy efficient homes lowers energy use, reduces overall energy demand in the economy and makes individual households, and Wales, more resilient to fuel price fluctuations.

There is more information about housing in our cohesive communities’ goal summary.

Social isolation and loneliness

Social isolation can reduce independence and damage mental health in particular, but can also lead to problems with physical health if services such as GPs, dentists and active leisure and social opportunities are inaccessible. There are particular concerns about social isolation of young and older people throughout the two counties.[10]  The rural nature of both local authority areas means that both have areas with poor access to services from a travel and transport perspective. For example, there are higher than average levels of deprivation in the access to services and physical environment domains of the Welsh Index of Multiple Deprivation –  7 out of 9 of Conwy County Borough’s Lower Super Output Areas are amongst the 10% most deprived in Wales for access to services. We also observe areas and groups of people (poorer households, the disabled, and older people for example), with poor levels to digital technology which may also contribute to social isolation. The intersections between isolation and health will have been exacerbated by the Covid-19 pandemic. It is anticipated that people who were lonely before the start of the Covid-19 pandemic are lonelier, and others have experienced loneliness for the first time.

It is almost certain that life will not return to how it was pre-Covid-19. Working from home, for example, is likely to continue for some or all of people’s working weeks. This has been a welcome adjustment to many, and has reduced the need to travel and enabled people to balance their home and working lives more easily. For others though, the adjustment has brought about feelings of isolation and loneliness. There may also be a loss of connectivity and innovation through reduced face to face contact. Local remote working hubs may help to address this and provides opportunities for local economies, businesses and the environment.[11]

Social care and health sectors

We have seen, and expect to continue to see rising demand for health and social care services at the same time as experiencing recruitment problems in both of these key sectors. A key challenge for health and social-care sectors is dealing with the delays in operations, appointments and disruption to other routine health services caused by the Covid-19 pandemic. It will take some time to ‘catch up’. What-is-more, there is evidence to suggest that demand for mental health support in particular, has increased further following the social distancing and other restrictions placed on people’s lives since March 2020.

Furthermore, ONS data cited by the Wales Centre for Public Policy indicate that a higher proportion of NHS staff and teachers have had Covid-19 condition compared to other occupations. This may have long-term implications for the health service and teaching professions (for example, should ‘long-Covid’ be persistent), as the we emerge from the pandemic.[12]

In this context the support needs of carers also need to be considered. Census data shows Conwy and Denbighshire have high numbers of people providing unpaid care with numbers much larger than appear to be known to health and care service providers.[13]  Some smaller areas, such as Conwy’s “East” sub-area, have high levels of limiting long term illness as well as a higher proportion of unpaid carers.

Digital health and well-being

Digital technologies could reshape the UK healthcare workforce. Digital medicine, artificial intelligence and robotics could significantly change the roles and functions of clinical staff by 2040, delivering improvements in patient care, labour productivity of healthcare staff and reduced costs. Telemedicine (provision of clinical care using telecommunication and information technology), smartphone apps and wearable sensors are all examples of technologies likely to be routinely used. Progress towards this has accelerated during the Covid-19 pandemic.[14]

We had seen a growth in online health consultations, more so in north west Wales, prior to the social distancing measures imposed during the Covid-19 pandemic. These increased exponentially during the lockdowns, and still continue to be in place for many health services, particularly in primary care. However, there is a growing concern and wish for face to face consultations.

In recent times, misinformation, or ‘fake news’, and social media have presented serious challenges to governments, businesses and people themselves. Examples include anti-vax campaigns, electoral tampering, ‘Covid is a hoax’ campaigns. Fake news is designed to undermine trust and confidence in democracy and public institutions. The World Health Organisation has started to refer to this as an ‘infodemic’. We do not currently have evidence to fully understand to what extent misinformation is causing people anxiety, or affecting Covid-19 vaccine uptake for example. The role and influence of misinformation (fake news) and its impact on our ability to fulfil our wider public health and civic objectives, is not yet clear.

Preparing for future pandemics

Infection prevention and control e.g. improving ventilation in buildings, importance of strong community networks, resilient communities etc, will form part of our ongoing preparedness for future pandemics. However, the scope and nature of future challenges is vast (see our ‘emerging threats to health and well-being’ topic for more information).

What people have told us

Concerns were raised around the mental health of young people, in particular following the impact of the Covid-19 pandemic on many areas of their lives. People are concerned about child poverty, and the extent to which the public sector is working to improve the quality of life for people and children in poverty. Child hunger is a particular concern for people and they want to understand the root causes for hunger. People also want to ensure we ask those living in deprived areas to find out what they feel would improve their lives in an attempt to ‘break the cycle’ of families being unemployed and dependent on benefits. People told us they would like to see life skills lessons or workshops in schools on subject such as managing finances, career advice, budgeting, mortgages and cooking.

The need to support healthy lifestyles was raised as a concern for people locally, particularly in respect of tackling obesity, through increased leisure opportunities, partnership working and by building on our active travel network. Active travel has been high on the agenda for the public as they want to see increased walking paths and cycling routes to neighbouring villages and towns.

People, particularly young people, have told us they find leisure facilities unaffordable and often under promoted so they are unaware of what is on offer to them or targeted at younger age groups such as infant or juniors, rather than older teenagers. Young people would like to see more investment in physical activity groups and facilities. One idea was to have accessible outdoor structures within local parks such as tennis structures.

From our engagement with the pubic, people have told us how they value access to the natural environment that is safe and clean. There have been concerns around litter issues throughout the counties. People told us they value community assets like community-run shops, pubs and businesses, and they want to encourage people, including young people, to get involved in their communities.

Access to affordable and good quality housing featured as a high priority for the public throughout our engagement. People felt there is a lack of housing stock and the price of houses and rental accommodation is becoming unaffordable for many. People want to see more social housing available to those in the communities who needed it. People have a good appetite to make their homes more efficient, however they would like support to make changes and some noted that they feel forgotten about as grants and support are often aimed at particular groups. Homelessness is seen as a factor in deprivation and so too housing quality. Poor housing has been highlighted by people as having a causal relationship with lower life expectancy.

They identified people with disabilities, including learning difficulties, and older people as people they feel should be supported, in particular to reduce feelings of isolation and loneliness. They thought that there could be ways of building generational links through younger volunteering to support older people.

People expressed their love and commitment to community groups as they connect communities and people of all ages. People want to see better support for these groups to set up and remain viable by having suitable and affordable facilities.

National priorities

Wales’ Programme for Government consists of almost 100 specific areas of activity. Among its ten well-being objectives are commitments to: “Provide effective, high quality and sustainable healthcare” and to “Continue our long-term programme of education reform, and ensure educational inequalities narrow and standards rise. Protect, re-build and develop our services for vulnerable people.” Pledges include:

1. Build on our School Holiday Enrichment Programme.
2. Build on the success of our concessionary travel scheme for older people and look at how fair fares can encourage integrated travel.
3. Continue our strong partnership with voluntary organisations across the range of our responsibilities.
4. Continue to support our flagship Flying Start programmes.
5. Decarbonise more homes through retrofit, delivering quality jobs, training and innovation using local supply chains.
6. Ensure that each region in Wales has effective and democratically accountable means of developing their future economies.
7. Ensure the history and culture of our Black, Asian, and Minority Ethnic communities are properly represented by investing further in our cultural sector and museum network
8. Explore radical reform of current services for looked after children and care leavers.
9. Fundamentally reform homelessness services to focus on prevention and rapid rehousing.
10. Implement and fund the commitments made in our Race Equality Action Plan
11. Introduce an all-Wales framework to roll out social prescribing to tackle isolation.
12. Invest in the learning environment of community schools, co-locating key services, and securing stronger engagement with parents and carers outside traditional hours.
13. Make our Welsh public transport system more accessible to disabled people.
14. Prevent families breaking up by funding advocacy services for parents whose children are at risk of coming into care.
15. Promote equal access to sports and support young and talented athletes and grassroots clubs.
16. Reform local government elections to reduce the democratic deficit.
17. Roll out child and adolescent mental health services ‘in-reach’ in schools across Wales.
18. Support cooperative housing, community-led initiatives, and community land trusts.
19. Support innovative housing development to meet care needs.
20. Use the new network of Disabled People’s Employment Champions to help close the gap between disabled people and the rest of the working population.

Opportunities for targeted interventions

The “Inequality in a Future Wales” report states:[15]

“An ageing population will disrupt how health and social care, employment and education, and pensions operate, and these systems will need to adapt if they are to function in the long-term. Future challenges need to be tackled with the needs of all generations in mind or risk disadvantaging one at the expense of another and/or falling short of achieving ambitions. A ‘care-led recovery’ puts childcare and the care needs of older people on an equal footing with ‘green jobs’ in benefitting health, the environment and the economy.”

[1] Dr Sara MacBride-Stewart & Dr Alison Parken (2021). Inequality in a Future Wales: Areas for action in work, climate and demographic change. The findings are summarised within a Summary Report and ‘Bite-size’ version with Easy Read and BSL versions available also. For those who are interested in the more detailed analysis you can access the full technical report.

Public Health Wales has highlighted important themes that can guide recovery from the Covid-19 pandemic:

• the importance of good social care
• the effect of mental health due to changes in socialisation opportunities
• the impact on those with job insecurity, both mental and financial
• community resilience and informal ways of working to solve problems
• recognising the importance of inclusion
• learning that public sector systems can work well together, and when there is the will, significant changes can be made to how care and support is delivered. [14]
• Research from Public Health Wales shows the potential health and societal gains if childhood experiences are improved. In population terms, if there were no adverse childhood experiences, there could be 125,000 fewer smokers across Wales and some 55,000 fewer people who have ever used heroin and crack cocaine. This is cost-effective; the evidence shows that just over £100 invested in prevention of ACEs will result in over £6,000 of savings when measured across all public services over the next five years.
• There are a number of ways in which ACEs can be prevented or their impact lessened, including raising awareness of their importance, providing appropriate services for all families and reliable access to additional support for those who need it most. The benefits from this work points to the value of joint investments and partnerships between the NHS, local authorities and other services and agencies to effectively prevent ACEs in the future.

Other Opportunities identified in State of Natural Resources Report 2020 (SoNaRR),

• Access to good quality green spaces for mental health and physical activities which can also contribute to a resilient environment and support cooling of urban areas
• Increasing the link of environmental services with social prescribing opportunities
• Shared work facilities or employment hubs such as the new Town Square Hub opened in Rhyl recently and can combat loneliness and isolation for those working on their own or self-employed.
• A shift of travel towards Active Travel rather than relying on short journeys in a car will increase activity through walking, cycling etc.
• The 20 minute neighbourhood concept is about designing an urban society in such a way that residents can meet most of their daily needs within a short walk from home. Safe cycling and local transport options are key to this, as well as high quality public spaces, community services and housing densities that make the provision of local services and transport viable. The 20 minute neighbourhood was pioneered in Melbourne, Australia as a way of guiding the city’s development and transformation to 2050. In order to achieve long term sustainable changes to travel habits – to secure a green economy – the culture change needed to achieve modal shift (a shift to active travel for short journeys and public transport for longer journeys), might be best focussed on children and young people.

Key questions and areas for further research:

• Once available we will consider the information that the North Wales Research and Innovation Hub are producing to support the regional populations needs assessment.
• We are not sure currently how we can balance opportunities posed by online services, which can remove travel barriers for instance and produce cost savings for services, with the challenges around the quality of the service from the user’s perspective. How big an issue is this?
• We need detailed analyses about the impact of Covid-19 on babies’ and children and young people’s health and well-being.
• To what extent are our communities long term resilience to climate change? Especially those communities at risk of flooding? And sectors of society which have determinants that make them more vulnerable to impacts of climate change on health?
• The impact of Covid-19 on housing, and its implications for health and well-being, is a gap that will require closer examination.
• The strength of the community in supporting social well-being, the nature of social networks, the social fabric of towns and towns and villages
• The role of the non-monetary economy in social well-being, physical assets, food banks, community asset transfer etc.) and levels (and strength) of unpaid care
• A UK Government trend deck states that many (60 to 80%) emerging infections are derived from an animal source. Infections have been emerging for thousands of years as humans have had more and more interactions with animals and their environment. Factors involved in emergence include microbial adaptation, ecological changes (the climate change emergency), human demographics and behaviour, international travel and public health infrastructure.[15] What does this mean for our areas?
• The role and influence of misinformation (fake news) and its impact on our ability to fulfil our wider public health and civic objectives, is not yet clear.
• Consider new research published by the Wales Centre for Public Policy in relation to loneliness in Wales.

[1] North Wales Social Care and Well-being Services Improvement Collaborative (2021), Locality Health and Social Care Needs Assessment North Wales.

[2] The wider determinants of health is one of Public Health Wales’s strategic priorities. Here’s their long-term plan and a range of publications can be accessed here.

[3] Protecting our Health: Our response in Wales to the first phase of Covid-19: Chief Medical Officer for Wales, Special Report

[4] Dr Sara MacBride-Stewart & Dr Alison Parken (2021). Inequality in a Future Wales: Areas for action in work, climate and demographic change. The findings are summarised within a Summary Report and ‘Bite-size’ version with Easy Read and BSL versions available also. For those who are interested in the more detailed analysis you can access the full technical report.

[5] Denbighshire County Council (2020). Welsh Index of Multiple Deprivation 2019: Results for Rhyl.  Un-published report.

[6] Source: Gap in life expectancy at birth between the most and least deprived fifth, 2015 to 2017. Public Health Wales Observatory, using PHM & MYE (ONS), WHS & WIMD 2014 (WG)

[7] https://phw.nhs.wales/news/wales-faces-unprecedented-triple-challenge-to-health-and-wellbeing/

[8] Letter from the Independent Chair, on behalf of SCHOPR members, to the UK Chief Medical

Officers. (July 2019). Health of the public research principles and goals. https://acmedsci.ac.uk/file-download/70826993

[9] Public Health Wales, 2019

[10] The data shows that twice as many younger adults say they’re lonely more than older people. Percentage of people who are lonely by age and gender (gov.wales)

[11] https://gov.wales/remote-working

[12] Wales Centre for Public Policy (2021). Briefing on well-being and the impact of Covid-19 and Brexit.

[13] https://www.northwalescollaborative.wales/carers/

[14] Government Office for Science (2021). Trend Deck. See also https://www.northwalescollaborative.wales/engagement/covid-conversations-partner-conversations/
https://www.northwalescollaborative.wales/engagement/covid-conversations-public-survey/
https://www.northwalescollaborative.wales/wp-content/uploads/2020/11/NW-Population-Assessment-Rapid-Review-2020-1.0.pdf

[15] Dr Sara MacBride-Stewart & Dr Alison Parken (2021). Inequality in a Future Wales: Areas for action in work, climate and demographic change. The findings are summarised within a Summary Report and ‘Bite-size’ version with Easy Read and BSL versions available also. For those who are interested in the more detailed analysis you can access the full technical report.

[16] North Wales Social Care and Well-being Services Improvement Collaborative (2021), Locality Health and Social Care Needs Assessment North Wales.

[17] Government Office for Science (2021). Trend Deck