The pressures facing the health of the population in Wales are visible in every community: rising levels of ill health and flattening life expectancy curves, together with widening inequalities, exhausted and demoralised NHS and social care staff and a system that too often reacts to crisis rather than preventing it. Our patients complain that they can’t get to see their GP easily, and that the wait for secondary care appointments and treatments is too long.

After 37 years as a GP in the NHS, I have seen extraordinary changes in medicine, technology and the needs of our communities. We can do so much more for our patients, but we are also seeing significant and steady rises in chronic disease prevalence, multi-morbidity and unhealthy lives. Meanwhile, the fundamental design of the NHS has barely shifted in over 70 years. It remains shaped around acute care, not the realities of modern Wales, and the system is now buckling under pressures it was never built to withstand.

There is good international evidence for the efficacy of primary care on population health, that means it must sit at the heart of every serious conversation about the future of our health and care system here in Wales. If we want a fairer, healthier Wales, we must begin where most care begins in our communities – in primary care. We need to recognise that ‘health matters’ for the health and economy of Wales – not as a slogan, but as a principle that should shape every decision we make. Small changes or ‘tweaks’ will not solve our problems – we need transformative change.

The reality we face

The data is stark. Wales is ageing. Chronic disease is rising. Poverty and inequality, which are consistently among the highest across the UK, are driving illness at scale. Twenty‑three percent of our population lives in poverty, with 29% of children in Wales living in relative income poverty. In these communities, people live 10–17 fewer healthy years, and avoidable mortality is almost four times higher. Meanwhile, the number of people living with major illness is projected to grow 3.5 times faster than the working‑age population.

These inequalities are not inevitable. The Bevan Commission, Public Health Wales, the Health Foundation and the Welsh Government’s own scientific advisers all point to the same evidence: targeted prevention, early‑years support, improved primary care access and place‑based interventions deliver the biggest health gains. In England, the NHS Confed (Aug 2023), reported that for every £1 spent on primary or community care by Integrated Care Boards, local economic output will increase by £14 – meaning that greater economic growth effectively pays for itself through increased tax receipts.

It is well recognised that general practice remains one of the NHS’s greatest assets: skilled at understanding the full mix of issues people bring, well prepared to manage holistic care for our increasingly complex patients, rooted in communities and uniquely placed to deliver continuity of care. Yet primary care receives just 7.4% of the NHS budget, even less than it did 20 years ago despite the growing needs.

The result is a system under intolerable strain, with both the General Medical Council (GMC) and The Health Foundation reporting that GPs across the UK have the highest levels of stress across the whole medical profession (including in comparable European countries), the lowest satisfaction with work‑life balance and the greatest intention to leave patient‑facing roles. In Wales, the pressures are compounded by workforce shortages, underfunded premises and a contract model that no longer reflects the realities of modern general practice.

In the face of ever-increasing demand for healthcare, there is a real need to increase the number and length of GP appointments so that patients can be seen faster, and to do that we need many more GPs alongside a more integrated multidisciplinary support team for GPs based around patients’ needs. We also need more GPs to manage the increasing complexity of patients we are managing in the community, and to support some of the community-based changes needed in healthcare. Social care, patient education and social prescribing services linked into practices are also important in helping patients find the best solutions for them, especially those who present bio-medically, but whose problems are rooted in non-medical factors such as housing, relationships, employment, poverty and loneliness.

Without significant changes in prevention, service design and community-based care, we will continue to see accelerated and unmanageable demand across the system, which will soon be overwhelmed. These changes need to start now, building upon the commitment from the new Welsh Government, which has recognised the importance of greater investment annually for primary care alongside engagement with patients, communities and other health and care professionals.

Transformation, not tinkering

If we want a sustainable NHS, we must redesign primary and community care from the ground up, to meet people’s needs where they live, work and play. We must ensure that we keep those aspects of patient care that are evidence-based and effective, while redesigning the service for those patients who are more complex and require a co-ordinated, personalised and multi-disciplinary care pathway to remain healthy.

At the same time, we need to focus on prevention and ways to keep our communities healthier for longer. This is not about marginal gains or incremental improvement. It is about shifting the centre of gravity of the system, improving services to suit the needs of our ever increasingly complex patients and bringing them into the community and nearer to the patient.

The service I see for the future will consist of four basic layers, the base of (or first of these) which will retain current universal access to healthcare. This will be done largely through primary care that includes general practice, opticians, pharmacists and dentists, as well as community-based teams addressing social care, mental health and musculo-skeletal health. This will provide an everyday acute service and chronic care for non-complex conditions and will be open to all for both same-day and routine care appointments. It will also provide routine vaccinations for children, pregnant mothers, older people and those with chronic conditions and will remain based on general practice registers of patients.

Above this existing base layer should be a ‘community health service’, or second layer, that spans several general practice footprints in size (for example, GP cluster sizes) and contains GP-led multi-disciplinary teams of health and social care professionals for those patients who require a more personalised care package. This would include a community frailty service (working 24/7) and services for patients with multiple long-term chronic conditions. It would also include other services dictated by local need, for example, patients from vulnerable groups such as homeless people, asylum seekers, looked-after children and prison communities.

Secondary care/ intermediary services will also be based in the community, as they are currently, including musculoskeletal, palliative care, pain clinics, podiatry and dietetics. Community diagnostic services would also be available at this level, sited in community health centres or community hospitals, an expansion of the Rapid Diagnostic Centres that already exist in Wales. Community mental health teams and community women’s health teams also operate at this level. Out of hours care should be run by GP co-operatives. This community health service would also be the layer that integrates horizontally with local authority services, such as social care and housing, and voluntary sector and community services, including referrals to and from social prescribers.

Above this would lie the existing secondary care (the third layer) and tertiary care centres (the fourth layer), but everything that could possibly be run in the community – including most outpatient clinics – would come out of general hospital settings and be sited in either community hospitals or community health centres.

In many places, aspects of these community-based services already exist, but they are not co-ordinated, patient records are not shared and there are many wasted efforts and silos as different services contact the same patient. In comparison, a co-ordinated personalised care approach would be both safer and more efficient. Bringing everything together would be much better for the patient and could be ‘held’ by GP practices, allocating to others as appropriate but with a special focus on managing complex cases.

The prevention agenda will need to be viewed from both a primary and a secondary prevention stance, incorporating general practice and other primary care services and working alongside public health services to ensure prevention initiatives are co-ordinated and get the best value for effort. Patient education, effective communication and dialogue with the public and with community leaders is also a vital part of this transformation, to ensure people are informing and shaping the changes and there is local accountability to people in our communities.

For me, transformation means:

• A stronger primary and community care voice that represents communities as well as primary care in national leadership, shaping decisions rather than reacting to them.
• A new GP contract that reflects modern practice, funds continuity of care and weights resources toward areas of greatest deprivation.
• Resources following work that is moving into the community, so that at least 11% of the NHS budget is allocated to primary care (as previously, in 2008).
• A workforce plan to increase the number of GPs and other supporting professionals in the NHS, including both increased training numbers as well as retention schemes, improved working conditions, the provision of occupational health to NHS staff in general practice, and modernised premises.
• Careful re-working of multi-disciplinary teams, ensuring everyone is working to their role description and in co-operation, with time set aside for appropriate, safe supervision if needed.
• Co‑located neighbourhood health services, bringing together GPs, community teams, diagnostics, mental health, social care and the voluntary sector.
• Digital systems that function, with shared and unified patient records, and secure, seamless communication (integrated working with patients will not work without this). An NHS App that provides patients with the facility to communicate with their practices to book appointments, request prescriptions, see their test results and letters and ask questions.
• A recommitment to the principles of prudent health and realistic medicine, with action to reduce low‑value medical interventions and wastage, co-ordinated personalised care to complex patients and supporting shared decision‑making.
• An integrated national prevention policy that incorporates the public, local public health services, Public Health Wales and other key partners, such as education and local government.
• A commitment to improving capacity for and linking more effectively with social care, both at home, and residential/ nursing home places, to find the best solutions. This will also reduce the pressure on A&E, admissions and ambulance waiting times.
• A cross‑government approach to the social determinants of health, including housing, poverty, early years and fuel insecurity, without which the NHS will remain trapped in crisis response.

This is not a ’nice to do’ list. It is the essential minimum required to stabilise the system so that primary and community care can work at its best for patients.

The barriers are real – but so are the opportunities

Transformation is difficult. It requires honest conversations about decommissioning low‑value care, reinvesting in prevention and primary care and concentrating on teamworking and co-ordinating care. It will require changes to funding streams at a time of fiscal constraint. It may result in choices that may not deliver immediate political wins. It requires transparency, communication and genuine partnership with clinicians and communities.

But looking the other way is not an option. The alternative is worse; a system that continues to buckle under demand, losing staff, public trust and the ability to deliver the care that the people of Wales deserve.

There is no shortage of vision. There is no shortage of evidence or committed clinicians ready to lead change. What I am suggesting is not rocket science. What has been missing is the political will to redesign the system around the realities of modern Wales.

The question now is this: Will Wales choose to transform primary and community care, not in rhetoric, but in action, so the nation can build a fairer, healthier future?

Because if we always do what we’ve always done, we’ll get what we’ve always got.

And Wales deserves better.

Those of us of a certain age might remember the medical ‘MOT’ – which, in today’s NHS, seems like something from a parallel universe in a different time. I’m not suggesting we bring it back, but it does evoke memories of a closer patient-doctor relationship that I think we’re missing in today’s digitally-driven era. 

When I was growing up, our large village in the Amman Valley had three doctors – a husband-and-wife team and an Irishman who could only be described as ‘six cylinder’, such were his many qualities. This Irishman, no matter your ailment, had a rapid three-point plan if he hadn’t seen you for some time; he would simply say: “Stick out your tongue, turn over your hands and let me see your eyes.” This quick MOT was carried out in an era of twice-daily, packed surgeries, house calls and night visits. He knew his flock well – to the point where, if the Monday morning regulars who attended just to get a ‘doctor’s paper’ for a week off didn’t show, he thought they must be really ill. 

Now the village has no GP and the morning ritual has entirely changed. The 8am phone call sees patients in a showdown for the golden ticket: admission to the doctor’s surgery. If one is fortunate enough to get an appointment, the next hurdle to actually seeing a doctor is the receptionist’s questionnaire, where your responses could see you downgraded to a phone call from the GP.  

In my role as a Bevan Commissioner, I am privileged to represent patients and the public, and at times this means listening to complaints. These include concerns about the effectiveness of phone calls, a viewpoint with which I have some sympathy, given the ‘optics’ of going to the surgery only to be greeted by an almost empty waiting room. GPs are undoubtedly working harder than ever, yet, for the patient, the sense of disconnect is only exacerbated by such scenes. So, does this template need reviewing, or are results being achieved – albeit without an avid audience? 

I must point out that my own surgery is excellent and I hear of other surgeries and medical centres which merit very real acclaim. In many communities the patient-doctor relationship remains personal and warm – yet we have all heard anecdotes about a breakdown in good practice. The development of larger surgeries with more staff has possibly distanced this relationship further, as has the closure of some local surgeries in favour of larger, centralised health centres, where you are less likely to see the same GP each time you attend.  

A friend of mine had an appointment with the GP about one ailment and, in passing, he mentioned that three weeks previously he’d had a blood test at the surgery. Were the results back yet? On checking his laptop, the doctor replied that they were indeed – but that my friend would need to make another appointment to discuss them due to the surgery’s ‘one ailment or query per visit’ policy. There is no doubt that the Bevan Commission’s Silly Rules National Report, written in partnership with patient body Llais, is needed as a practical call-to-action to take away such barriers and place the patient at the centre of their own health and care. Instead, my friend felt like an inconvenience to the service that should have had at its heart what was best for him. 

Since the days of my Irish doctor’s MOTs, life has changed in many ways, and not just in the medical world. Think of all the times you have phoned a company or organisation, be it in the care sector, finance, transport, retail or your local council, only to be greeted by a recorded voice offering you a series of options, several times over. Religious venues are closing and between six and eight pubs are being lost every week in England and Wales (although, in 2026 to date, this trend is starting to reverse in Wales). After listening to concerns from patients and relatives about access to services, I have often considered whether holding a surgery once or twice each week, especially a rural area, would be a boon. After all, banks now do it in hubs – why not health services? 

Of course, today there is an app for your every need and technology can help to make healthcare easier, safer and more efficient. Yet digital services remain out of reach for many, and I venture to suggest that there is a disenfranchised tribe out there; people who do not use laptops or smartphones. Dare I suggest that, in view of the rate of Post Office closures – again, particularly in rural areas – providing pharmacy facilities at these sites could be a step forward? 

Going back to those early-morning scrambles for a GP appointment we must mention A&E departments. Today these are visited by parents carrying small children who are clearly very ill; without access to a GP, they may feel they have no other place to venture to or call and are desperate. In the days of the medical MOT, there was another alternative to A&E – the doctor who worked nights and, where necessary, was followed by treatment nurses. These angels came when they were needed and their efforts were a truly uplifting experience. 

Today, countless healthcare professionals are working relentlessly, in challenging circumstances and without adequate resources, to give the best possible care to patients. But I would argue that it is time to put the patient experience back at the centre of everything we do, instead of trying to make patients fit around the service. 

As a new era for Wales gets underway following the historic Senedd election in May, Aneurin Bevan’s legacy demands more than preservation – it demands courage. As Plaid Cymru set out in its manifesto: ‘The NHS, once the envy of the world and the pride of our nation, now faces relentless demand and overstretched resources.’ If the NHS is to resume its place as the jewel in the crown, we have a moral and ethical duty to ensure it is sustainable, resilient and genuinely fit for the future. That won’t be achieved by repeating what we’ve always done or waiting for permission to act.

Nearly 80 years on from its creation, the NHS is operating in a world its founder could never have imagined. Rising long‑term conditions, demographic change, workforce pressures and rapid technological advances mean that standing still is no longer an option. The question is not whether the NHS should evolve, but whether we are willing to shape that evolution together.

Some argue the NHS must remain untouched. But while its founding principles are timeless, the way we deliver care needs continually to adapt. The real challenge is how we bring people, professionals and communities into the conversation, so the system reflects the needs of today and tomorrow.

For decades, we’ve known what needs to change:

• a stronger focus on prevention
• smarter use of technology
• redesigned services
• new ways of working

Yet turning evidence into consistent practice across Wales remains difficult.

Wales has the ingredients to lead. We are the right size, with strong networks and a passionate, skilled workforce. Through our Bevan Exemplars and Fellows, we see daily the creativity and commitment that already exists. But without collective purpose, the risk is clear: the NHS will slowly wither while poverty, sickness and inequality deepen. So what is holding us back?

To move forward, we must shift our mindset. Health is everyone’s business. Around 85% of what shapes our health happens outside the NHS in our homes, workplaces, communities and environment. If we want people to live healthier for longer, we must make healthy choices the easy choices.

The NHS excels at treating illness, but lasting wellbeing depends on addressing the wider determinants of health: education, employment, housing and community resilience. “Health in all policies” must become reality, not rhetoric.

Change is never easy. Top‑down directives rarely create lasting transformation, and the public can be wary of change especially when it touches cherished local services. Yet our conversations with communities show something different: a real appetite for honesty, involvement and more radical thinking when people feel respected and heard.

We must get better at listening. Not just consulting but working with people as partners. When frontline innovators are trusted and supported, new ideas flourish, collaboration grows and change becomes something people own rather than resist.

We must also be more prudent, creative and integrated. Our recent work on system flow and “silly rules” shows how outdated practices still waste time and energy. If we are serious about improvement, we must stop doing what no longer adds value.

The ambition is clear: healthier, thriving people and communities across Wales. Achieving it requires collective effort; not passive observation, but active participation.

The future of health and care will not be secured by preserving the past unchanged. It will be shaped by our willingness to learn, collaborate and, above all, be brave enough to change. This is the heart of Health Matters: recognising that the choices we make today will determine whether our system survives, or truly thrives, tomorrow.

Health matters. It matters to every one of us from the moment we take our first breath, shaped profoundly by the people around us and the communities to which we belong. Across the world, governments are recognising that social connection is not a luxury but a foundation for health. The evidence is clear: belonging, supportive relationships, and meaningful connection are as vital to wellbeing as any clinical intervention.

If we want to unlock the sustained economic growth so often described as the Holy Grail of politics, we must do more than acknowledge this truth. We must enable health, social care, education, the world of work, and justice to operate as one system, working in genuine allyship with the people they serve. Allyship is not a slogan; it demands curiosity, courage, and commitment.

Nowhere is this more urgent than in mental health. A mental health ally is an informed, empathic person who listens without judgement, connects people to support, and champions understanding across the whole system. This is the cultural shift Wales needs—one that recognises that health is shaped not only in hospitals and clinics, but in homes, workplaces, schools, and communities.

And because health is shaped across the whole life course, we must pay particular attention to the environments in which children grow. Children live in families, families live in communities, and communities are anchored by schools. The Well‑being of Future Generations Act recognises that giving children the best start is essential to lifelong health. Supporting this vision requires a shift in how we train the workforce across health, social care, education, and justice.

But for all of this to happen we need to function as a system, we must learn to agree well and disagree better. Perceived complexity frequently serves as a justification for inaction. In many cases, what is seen as complexity is simplicity obscured by multiple demands and differing perspectives.  The goal remains simple: more people healthy and coping, and far fewer struggling or unwell.

In the current climate, it can feel as though we move from one crisis to another. But shifting from chaos to culture requires clarity about what culture truly is: the shared way of life of a group of people, their beliefs, customs, values, behaviours, and knowledge, passed across generations. It shapes how we see the world and how we act within it.

Wales is rich in visible culture, but the deeper layers matter just as much: the core values and assumptions that guide how we work together. These deeper layers are harder to change, but they are also where transformation begins.

Systems thinking helps us to distinguish between constant change and genuine transformation. As Gaius Petronius Arbiter observed in 66 AD, “We trained hard, but it seemed that every time we were beginning to form up into teams we would be reorganised.” Reorganisation can create the illusion of progress while generating confusion, inefficiency, and demoralisation. Wales must resist this trap.

If we are serious about moving from chaos to culture, we must recognise the tools already in our hands. Wales does not lack ideas, evidence, or goodwill; what we often lack is the confidence to use them boldly and consistently.

Collaboration is one of the most powerful levers, not the version that appears in strategy documents, but the kind that emerges when people genuinely work together with shared purpose. Collaboration is a mindset: leaders creating the conditions for trust; citizens treated as partners, not problems; organisations recognising they are part of a bigger whole, not competing islands. When collaboration becomes the norm, systems begin to move.

Kindness is another lever, not the soft version, but what Ballatt and Campling call intelligent kindness. It recognises that our wellbeing is interconnected and that compassion is a driver of quality and safety. When leaders act with intelligent kindness, it changes the emotional temperature of a system. People feel seen, able to speak up, and able to care. When that happens, everything else becomes possible.

We must also understand the power of identity and belonging. Decades of social science confirm what practitioners have long known: people stay well when they feel part of something. Belonging, whether to a family, school, workplace, neighbourhood, or cultural community, gives people the psychological and practical resources to cope with life’s challenges. When services nurture belonging rather than erode it, we unlock what the Haslams call the “social cure”.

These levers are not abstract theories. They are the foundations of a health and care system that works. They are also deeply Welsh values. If we choose to centre them, they can help us build a culture that supports people to thrive, not merely survive.

In these times of political flux, the words of Aneurin Bevan resonate: “Illness is neither an indulgence for which people should pay nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.”

The risk today is that competing needs push essential actions into the “too difficult” box. But health matters too much for that.

We must ask:

• Are we meeting the needs of the Welsh population?
• Are we delivering the best care everywhere, for everyone?
• Are we eliminating unwarranted variation?
• Are we choosing wisely and ensuring value for money?

This is prudent healthcare in practice. Quality improvement is not a luxury; it is the solution to our current challenges. As Sir Don Berwick, a fellow Bevan Commissioner, states the aim is simple:

• No needless deaths
• No needless pain or suffering
• No helplessness in those served or serving
• No unwarranted variation or waste
• No one left out

These principles are not abstract ideals. They are a practical blueprint for a fair, effective, and compassionate health and care system.

Wales stands at a crossroads. The pressures on our health and care system are real, but so too is our capacity for innovation, collaboration, and collective courage. If we act with intention, guided by evidence, compassion, and shared purpose, we can build a culture that supports people not only to survive, but to thrive.

Health matters. Culture matters. And the decisions we make now will shape the Wales that future generations inherit.

Where would we be without the social care workforce in Wales? It is a question we rarely pause to ask, yet the answer underpins the safety, dignity, and independence of thousands of people every day. If we are serious about building a fair and thriving Wales, we must start by recognising that health matters — and that social care is inseparable from the health of our nation.

The primary role of social work and social care is to empower and protect those children and adults who may be at risk of harm or loss of independence. Those risks can arise from neglect, abuse, frailty, illness, disability, or simply a lack of support.

For many of us working in the public sector, it is easy to take for granted that our children will eat healthy food, live in warm homes, receive a decent education, and be free from neglect or abuse. As adults, we expect to manage our own personal care, finances, and daily lives, and to enjoy social, educational, and leisure activities without assistance.

But this is not the reality for everyone. And in this piece, I am focusing on adults.

Most adults want to experience “what matters” to them — a core principle of the Social Services and Well‑being (Wales) Act. Many can achieve this through their own networks of family, friends, and colleagues. But for adults who are frail, living with illness or disability, or at risk of harm, support becomes essential.

When those natural networks are absent or insufficient, the adult social worker steps in, assessing what outcomes the person wants to achieve, offering advice, and arranging the right support. Their task is to protect human rights, maximise independence, and ensure the person retains voice and control wherever possible.

Yet the system they work within is not always aligned to this purpose. Tensions often arise between NHS professionals and social workers when a vulnerable adult is deemed “medically fit” to leave hospital.

The political and operational focus on hospital activity does little to support the social worker who must ensure safety and independence beyond the hospital door. Rushed discharges can create real risks when care and support plans are not yet in place, plans that may require coordination across families, voluntary organisations, and commissioned social care workers.

Contrary to much of the public narrative, Social Services is far more than a discharge mechanism for the NHS. It is a critical public service, rooted in local government, with the ability to connect seamlessly with housing, education, leisure, community services, and the third sector. This local reach enables holistic assessments and coordinated responses that reflect the full complexity of people’s lives.

If we are serious about improving outcomes, the system needs a stronger focus on community‑based health and social care, preventing hospital admissions rather than managing delayed discharges. Many regions already have intermediate care services and community hubs that bring the third sector into preventive and supportive roles. With an ageing population in Wales, strengthening these out‑of‑hospital resources is essential, and funding must follow that ambition.

Some argue that formal structural integration between health and social care is the answer. But there are many ways to achieve better coordination without the disruption of major reorganisation. Wales already benefits from regional partnership arrangements that could be strengthened to deliver shared outcomes.

As Dr Hugh Alderwick’s analysis of OECD health systems reminds us, there is no perfect structure, social and economic factors are too complex. The priority should be improving the system we already have, not chasing an elusive ideal designed far from the frontline.

Language also matters. The NHS often talks in terms of patient flow, pathways, and process, shaped by political pressure on waiting times and treatment numbers. Social Services has its own performance measures, but far less public scrutiny. The result is predictable: political and public pressure drives funding toward the NHS, squeezing local authority and third sector budgets. Yet it is precisely that local capacity, the community support, early intervention, and preventive services, that reduces demand on the NHS and helps Wales cope with an older, less healthy population.

So where does this leave us? With a truth that is both simple and urgent: Wales cannot deliver the health and wellbeing its people deserve without a strong, valued, and properly supported social care workforce. They are the quiet infrastructure of independence, dignity, and safety and their contribution is too often invisible until the moment it is missing.

As Wales approaches the next Senedd elections, there is an opportunity for every political party to recognise this reality. Not through slogans or structural upheaval, but through a clear commitment to strengthening community‑based care, investing in prevention, and valuing the workforce that holds so much of our social fabric together.

Because health matters. Social care matters. And the choices we make now will shape the Wales we become.

The challenges in delivering high quality safe and effective health and care services have never been more acute. The cost of delivering modern healthcare continues to rise almost exponentially as advances in science allow us to treat and often cure conditions that in the past could only be managed through palliative care. These scientific advances almost always have a high price and all healthcare systems wrestle with the challenges of deciding how best to invest its resources. If health matters we must confront these realities honestly.

The demand and capacity challenges are particularly acute, brought about by multiple factors including the demographic changes in our population and the rise in long term conditions including multimorbidity and frailty. When you add the workforce challenges, including the recruitment and retention of staff, and the requirement to upskill the existing workforce, it is not difficult to understand why things feel all too difficult at present!

It is important to emphasise that this is not simply a Welsh or a UK problem, it is the same in every nation around the world. Most of these challenges are not new, they have been with us for more than 30 years, but one emerging factor now demands our attention if we are to move our health and care system into a better place.

Over the past ten years we have seen a significant change in the public’s expectations when it comes to the services offered by our health and social care system. The days of people being satisfied and grateful for any service being delivered is long gone. People’s expectations are now much higher and they find it difficult to understand why services do not recognise and cater for their personal circumstances.

The fact that we live in an increasingly connected world where digital technologies are playing a prominent part in our day-to-day lives creates opportunities for both health and social care services to respond in new and innovative ways. This has led me to coin the phrase “We require 21st century solutions to address our 21st century problems”. Continuing to pour time, effort and money into approaches that served us a decade or two ago is, at best, a sticking‑plaster response to a deep and complex wound.

To move forward constructively we need to make some bold decisions. If we simply continue to manage, for example, long term conditions in the conventional way we do today the healthcare system will run out of capacity to manage patients with cardiovascular or respiratory diseases in the next few years as the number of new patients continues to rise and those living with their disease live longer.

So, how do we cope? We cannot simply employ more doctors, nurses or therapists. The only affordable solution is to activate and empower our citizens to make better informed health and well-being choices so that they do not increase their risk of developing a long-term health problem while at the same time creating an environment where people can actively manage and deliver more of their own care. This seems easy to say but is very difficult to deliver as it requires a move away from the maternal or paternalistic medical model of health care that stood the NHS in good stead during its first 50 years of existence.

However, we do have the tools to make this happen through the advent of digital technology innovation.

To unlock the significant benefits that digital technologies can bring you first have to ensure you place the individual at the centre of all that you do. User centred design is going to be fundamental if we hope to maximise the benefits from any future financial investments in digital solutions. Services must be built around users, not organisational needs, and the design of a digitally enabled service matters as much as the technology itself.

We know that the more things we know about an individual patient or service user the easier it is to personalise the services to meet their needs and so increasing the likelihood that the solution will be used.  To do this we require data. For too many years the only healthcare data that the NHS trusted was the data it generated itself. We now have the capability to pull data from multiple public sector systems and from other sources to better understand the lived experience of our citizens. This allows us to build digital tools and products which can be put in the hands of our population to allow them to curate their own data and make better informed health and well-being choices. It can allow them to access services on their own terms, tell their story only once, and access services at the most appropriate time to meet their individual needs. This future is not imaginary from a technology point of view; these capabilities exist today. However, it will require a cultural shift to secure the benefits that this approach can bring.

If citizens were given the opportunity to hold their own data and give permission for it to be shared with whoever they choose, it could transform how we deliver health and care. If health matters then citizen‑centred data sharing could be one of the most important steps we take toward a more responsive, prevention‑focused system.

After a lifetime spent working alongside people facing financial hardship, one truth has become impossible to ignore: health matters, and Wales cannot fix its long‑term health challenges without confronting the economic realities that shape people’s daily lives. Yes, we must deal urgently with waiting lists, emergency care pressures and the worrying state of our population’s health. But unless we address the financial insecurity that underpins so many of these issues, we will be treating symptoms, not causes.

Financial wellbeing is not a luxury. It is a fundamental determinant of health. The Money and Pensions Service describes it as feeling secure and in control of your finances—able to pay today’s bills, cope with the unexpected, and build a stable future.

When people cannot afford the basics—food, heating, transport, rent—their health suffers. Poor financial wellbeing shortens the years people live in good physical and mental health and contributes to premature death. It worsens existing conditions, fuels mental distress, and forces people into a cycle where money worries and health problems reinforce each other.

Stress and insecurity make healthy choices harder. People under financial strain are less likely to eat well or exercise, and more likely to turn harmful behaviours such as smoking, alcohol or gambling. Cold, damp homes—unaffordable to heat—exacerbate respiratory illness. And poor health itself becomes a barrier to financial stability, limiting access to education, secure work and the support services that could help people regain control.

The burden is not shared equally. Research from the University of Bristol (2024 Financial Wellbeing and Ethnicity report) shows that white householders are twice as likely to be financially secure (30%) as those from black or other ethnic backgrounds (15%), and groups such as social renters, lone parents and people with disabilities or a long-term condition are far more likely to experience low financial wellbeing. These inequalities ripple across families, communities and generations.

A Healthy Wales must be a Financially Secure Wales

If we are serious about improving health in Wales, we must recognise that health matters in every aspect of life—including the financial. Financial wellbeing must be treated as a core building block of public health, every bit as essential as access to GPs or hospitals. When people feel secure with their money, they are happier, experience less chronic stress, participate more in their communities, and are better able to make healthy choices which leads to longer and healthier lives. They also rely less on NHS services, easing pressure on a system already stretched to its limits.

This is not simply about ensuring people have “enough” money to be financially secure. It is about ensuring people have the confidence, skills and support to manage their finances throughout life, from pocket money to pensions. Schools, workplaces, communities and public services all have a role to play in building this foundation, ensuring both thriving people and communities.

Prevention must be more than a Slogan

Wales already has the frameworks to support this shift. The Bevan Commission’s Prudent Healthcare Principles, the Social Model of Health and Care, and the Wellbeing of Future Generations Act all emphasise prevention, fairness and long‑term thinking. The Cymru Can Strategy commits public bodies to tackling the root causes of ill health and reducing inequalities.

But these commitments must now be matched with action. We need a Senedd that recognises the inseparable link between universal access to health and social care, economic security and decent housing. We need policies that treat financial wellbeing as a public health priority, not an afterthought.

A Moment for Courage and Clarity

There is no avoiding the economic cost of health inequality. Taxation may need to rise to meet the scale of the challenge—but this moment also offers an opportunity to rethink how we use to protect the most vulnerable, strengthen financial resilience and reduce health inequalities for good.

As my fellow Bevan Commissioner Sir Michael Marmot reminds us, “There can be no more important task for those concerned with the health of the population than to reduce health inequalities.” That must be the measure of our success.

As Wales approaches the Senedd elections, we have a choice: continue to firefight the consequences of poor financial wellbeing or finally confront the root causes. If we choose the latter, we can build a healthier, fairer and more resilient Wales.

Early in my public health training, a simple image crystallised the entire concept of prevention. A person returns home to find it flooded and immediately starts bailing water with a bucket. The instinct is understandable, but the logic is flawed. The real solution is not to bail faster, but to turn off the tap. It is a reminder that health matters most when we act before harm occurs, not after.

Despite our ritualistic reverence for the phrase “prevention is better than cure”, the Welsh NHS — like the wider UK health system — remains fundamentally and stubbornly a treatment service. The question, then, is not whether prevention works but why, after decades of rhetoric, we have failed to build a system that embodies this truth. For Wales, the birthplace of an NHS rooted in prevention, universality, and social justice, this failure is more than a technical policy error. It is a betrayal of the service’s founding spirit and a neglect of the simple reality that health matters to every aspect of our national life.

Wales is uniquely positioned to do better. Devolution provides the levers for cross-sector action. Our population is receptive to change. What we lack is not ambition, but the ability to follow it through.

The Perverse Logic of a Treatment First System

The prevention agenda does not fail because it lacks evidence; it fails because it collides with a system structurally hardwired for acute care.

First, the Welsh NHS is organised, funded, and judged almost entirely on activity: admissions, operations, waiting lists. Success is measured by how much illness we treat, not how much we prevent. Budgets reward intervention, not avoided harm. A health board does not receive additional funding because rates of Type 2 diabetes fall in its population; it is rewarded for treating more complications once the disease has taken hold.

Second, prevention suffers from a brutal political reality: invisibility. Politicians and system leaders gain recognition from visible acts such as opening new hospital wings. Preventative success is defined by non-events: the heart attack that never happens, the cancer that never develops, the child who never becomes obese. These outcomes are slow, statistical, and difficult to dramatise. Their benefits often emerge well beyond a five-year Senedd term. Political credit flows downstream to cure, not upstream to cause.

Third, cultural bias runs deep. We operate with a medicalised understanding of prevention, prioritising screening and early diagnosis over the harder work of addressing poverty, housing, food and employment. Acute care is celebrated, while the long-term impact of public health work is overlooked. This bias shapes public expectations: people seek immediate solutions instead of long-term investment in the foundations of health.

Finally, prevention fails because responsibility is fragmented. Health is influenced by housing, transport, education, and work, but responsibility for these factors is spread across separate institutions with conflicting financial incentives. The organisation that invests in prevention rarely captures the savings. A GP who prevents an admission saves money for a hospital, not for primary care. Unsurprisingly, NHS spending on prevention has fallen sharply over the past decade.

The Consequences We Can No Longer Ignore

The result is a system that is financially unsustainable and socially unjust. We continue to pour resources into bailing water while the tap runs unchecked. Long-term, preventable conditions such as cancer and diabetes now consume a growing share of the NHS budget. This is not bad luck; it is the predictable outcome of a system that allows demand to be endlessly generated upstream.

The social cost is even starker. The people struggling are overwhelmingly from our most deprived communities. In Wales, postcode remains a stronger predictor of health than genetic code. A child born in the most deprived areas can expect a decade fewer years of good health than one born in the least deprived. Poverty is a slow-burn toxin: driving stress, limiting food choices, and trapping families in cold, damp housing that breeds illness.

A downstream system treats the asthma with inhaler but ignores the mould. It medicalises social harm and then quietly blames individuals for “lifestyle choices” they were never truly free to make, entrenching inequality across generations.

The paradox is this: we spend heavily and intervene often, yet population health remains poor. While life expectancy has risen, healthy life expectancy has stalled. We are keeping people alive longer, but sicker. The Bevan Commission has repeatedly warned that without prioritising prevention and population health, the Welsh NHS will remain financially, environmentally and socially unsustainable. If health matters, then our current trajectory is indefensible.

Transforming from Managing Sickness to Creating Health

Escaping this reactive loop requires more than strategies and speeches. It demands a rethinking of how we define success, allocate money, and share responsibility.

First, Wales must fully embed and prioritise Population Health Management. This involves moving from crisis care for individuals to proactive population health management. By integrating data across health services, local authorities, housing, and education, we can identify risk earlier, target interventions intelligently, and make prevention visible and measurable. This approach is not theoretical. We have demonstrated its feasibility in Wales. The challenge is scale and political will.

Second, we must rewire financial and performance incentives. Value-based models that prioritise health outcomes should replace activity-based funding. NHS, local government, and social care budgets should be pooled to ensure effective preventative measures are both practical and cost-efficient and safeguarded during times of acute need.

Third, prevention requires accountability that outlives electoral cycles. “Health in All Policies” should be a statutory duty across Welsh Government. Alongside waiting lists, we need a public dashboard that tracks things such as healthy life expectancy and child wellbeing – metrics that reflect whether we are actually creating health.

Finally, we need a new social contract. Prevention cannot be delivered by the NHS alone. Welsh Government must act as an enabling state, using its powers to shape environments that make the healthy choice the easy choice. In return, the public should be empowered to help manage their own health and wellbeing, to co-create services and build communities.

For too long, Wales has remained downstream, bucket in hand, focused on treating poor health instead of addressing its causes, but this can and should change. Aneurin Bevan himself recognised that health depends on living conditions as well as medical care, and that a society should focus on preventing illness, not just treating it. Turning off the tap is both possible and necessary. As set out in Health Matters: Honouring Bevan’s Legacy, Securing Tomorrow’s NHS by Nygaire Bevan, the challenge before us is stark: continue managing sickness at ever greater cost or finally build a nation that creates health.

The NHS is not just one of Britain’s greatest achievements—it is the beating heart of our nation. In Wales, it is our sacred duty to protect it. My great uncle Aneurin Bevan built this service on the principle of fairness, determined that good quality healthcare should be available to all, free at the point of need. He overcame adversity in his own life with resilience and vision, and it was that same determination which drove him to create a system that transformed the lives of millions.

Today, as we look ahead to the Senedd elections, we must ask ourselves: are we prepared to show the same courage and imagination to ensure the NHS not only survives but thrives for generations to come? Because make no mistake, health matters, and without bold action, Bevan’s legacy is at risk.

Aneurin Bevan’s story is one of grit and conviction. A boy who struggled at school, who battled a stammer, who taught himself to speak by reading complex literature aloud while walking the mountains of his home. That resilience carried him into public life, first as a councillor and then as an MP. His politics was rooted in fairness and equity, and his vision for the NHS was simple but radical: healthcare should be universal, high quality, and free at the point of delivery.

He faced fierce opposition, but he never wavered. With passion and determination, he pushed the legislation through, and the NHS was born. It was his gift to the people—a service built not on privilege or policy alone, but on principle. As Nye said: “No society can legitimately call itself civilized if a sick person is denied medical aid because of lack of means.”

So, what would Nye think of the NHS today? He would still see a service loved and cherished (though too often taken for granted by the public), that meets the needs of millions every single day. But he would also see the cracks widening. An overreliance on ‘medical solutions’ where once people and communities filled the space. Waste that is invisible to most but drains precious resources and must be eliminated. Misuse and inefficiency of services that weaken the system and must be confronted head‑on. And above all, the urgent need for a new culture of shared responsibility for health and well‑being.

Wales, with its relatively small number of NHS health boards and trusts, has the capacity to act decisively and to lead by example. Yet too often we are paralysed by centralised control, by risk aversion, by timidity masquerading as caution, and by a lack of political courage and bold leadership. This is not the moment for hesitation. It is the moment to prove that ‘health matters’, that Bevan’s vision was not just a historic achievement but a living and thriving mandate. If we fail to act now, we risk betraying his legacy and denying future generations the service he fought so hard to build.

We already know what needs to be done. The Bevan Commission has already set out its thinking alongside supporting more than 800 Bevan Exemplar initiatives across Wales, to help find practical, innovative solutions to the challenges.  This has shown that change is possible building upon the knowledge, ideas, passion and commitment of those who work in the system. But innovation alone is not enough. We must work together to urgently adopt, spread, and embed these transformations across every health board, ‘pinching with pride’ and ensuring best practice is rolled out consistently. Only then can we deliver the best possible outcomes for people while creating a more prudent, efficient, and effective NHS.

This is the moment to be bold. We must rekindle Bevan’s energy and drive. Politicians and health leaders must be brave enough to act, not just talk.

And here lies the crux: we must move from words and rhetoric to doing and delivering. Speeches and promises will not heal patients, reduce waiting lists, or eliminate inefficiency. What will make the difference is action—rolling out proven innovations, tackling waste head‑on, empowering communities to take responsibility for health, and holding leaders accountable for delivery.

The NHS cannot survive on sentiment alone. It must adapt, innovate, and evolve. Protecting Bevan’s legacy means defending its founding principles whilst being open and receptive to change. That requires vision, and courageous leadership translated into tangible outcomes that make a real difference to people.

As the Senedd elections approach, the challenge is clear: will we honour Bevan’s legacy not just in words, but in deeds? The NHS was built on bravery and conviction. As my great uncle said: “The NHS will last as long as there are folk left with faith to fight for it.”  It will only survive if we show the same conviction and determination today – not through rhetoric but through urgent action. Only then will we have an NHS that is both sustainable and fit for the future.