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.