In his recent major speech on social care reform, Prime Minister Andy Burnham revealed that he had asked the crossbench peer Baroness Louise Casey to bring forward her review of social care from 2028 to 2027, in order to “rise to this challenge with the urgency it requires.” The review, said Mr Burnham, will explicitly outline a blueprint for delivering the Labour Party’s promise to set up a National Care Service that provides consistent care across England. Similarly, the Plaid Cymru manifesto contained a commitment to work towards a National Care Service integrated with NHS Wales. 

This opinion piece explores whether the establishment of a National Care Service in any of the four nations of the United Kingdom is likely to meet the future needs of people requiring social care support. I must start with a declaration of interest; I chaired the Independent Review of Adult Social Care in Scotland, which recommended a National Care Service to the Scottish Government in February 2021.  

I saw the creation of a National Care Service as an essential reform in Scotland for a number of reasons, including national level integration with the NHS and clearer accountability and assurance for Ministers, parliament and the public. It would align with national strategy and funding decisions, remove regional and local variation – in other words, the ‘postcode lottery’ – and introduce national terms and conditions for all staff. It would also serve as a vehicle to scale up and spread best practice, which is almost impossible in the current system. 

The Prime Minister’s statement contains echoes of the same rationale, and I would contend that similar challenges exist across Wales. Indeed, Plaid Cymru’s manifesto promises to instruct the new National Office for Care and Support to develop and implement standardised national guidelines on social care, with regards to the commissioning of services, data collection, and needs assessments, as well as working with local authorities and care providers to ensure that the Real Living Wage is the minimum wage rate for social care in Wales. 

Our current system of social care support is perfectly designed to get us the results it gets. Unfortunately, all too often for people who need support, those results are unwarranted variation, crisis intervention (at best) and an over reliance on market-based solutions. 

For the reasons outlined above, I continue to believe that a National Care Service needs to be part of any package of health and social care reform. However, as I recommended in 2021, it is only part of a much wider set of reforms that are required. 

Firstly, and perhaps most importantly, we need to change the prevailing narrative around social care. It is not some unsustainable burden, something that should only be available in a crisis or only for those confined to the margins of society. Rather, it is a positive and productive investment in our economy, our citizens and our human rights. 

A section of the Independent Review in Scotland called ‘A new narrative’ demonstrated the paradigm shift required. ‘Old’ thinking included social care support as a burden on society and something needing to be available in a crisis. It centred around competition and markets, was transactional and variable and focused on a fixed location for services, such as a care home. 

The new thinking is of social care support as an investment, enabling rights and capabilities. It is preventative and anticipatory, and centres around collaboration and  relationships. Crucially, it is a vehicle for independent living and is consistent and fair. 

Secondly, we need to close the implementation gap. Scotland, England and Wales all have promising policies and interventions. However, there is a big gap between the intent and the service reality. Social care is devoid of science-based implementation and improvement methods. 

Thirdly, we need to radically amplify the voices of lived experience. We need people who require social care support and the unpaid carers – who are the very cornerstone of the system – to be heard, represented and part of the decision-making process.  

Fourthly, we need to invest; in the social care workforce who do some amazing work for scant reward, and in prevention and early intervention. Some of these interventions, especially those around connecting people and reducing social isolation, cost relatively little. I have heard of multiple early intervention programmes for older adults, for example, which have achieved strong results at proof of concept stage, but which wither on the vine for lack of support to spread them wider. 

In short, based on my conversations with thousands of people in the social care system, a National Care Service is necessary, but not sufficient, for successful redesign of our social care systems across the UK.  Any structural reform needs to be accompanied by a shift in mindset and a step-change in implementation capability across the sector. Neither should social care continue as the poor relation of the NHS. If health and care are equally to matter, it needs parity of esteem and equal priority when it comes to funding. That will require some difficult decisions but investing in social care is an investment that will improve the lives of so many of our citizens. We need the courage to take those tough decisions. And for people in need of social care support, the time for change is now. 

Earlier this year, as Wales approached what turned out to be an historic Senedd election, the debate about the future of our health and care system intensified. The first piece in the Bevan Commission’s Health Matters, series by Nygaire Bevan – great niece of Aneurin – reminded us that the founding principles of the NHS were never meant to be static. They demand vigilance, renewal and the courage to confront uncomfortable truths.

With Plaid Cymru now having marked its first 100 days leading the seventh Senedd, my contribution to Health Matters continues in that spirit. It asks a simple but profound question: How can Wales claim to put quality and safety above all else when it does not have a formal, externally audited quality management system? If health matters – which it does, more than any political cycle or organisational preference – then the absence of such a system should be a concern.

This is not a technical quibble. It is the missing foundation stone of a modern, sustainable health and care system, and its absence is now visible across NHS Wales.

A legacy ignored

When the late John Wyn Owen became the first Director of NHS Wales in 1985, he introduced a formal quality management system to ensure that improvement was not left to chance or personality. He later became a Bevan Commissioner and he remained deeply disappointed that his successors dismantled the system he had put in place.

That decision has echoed through the decades.

Wales has invested heavily in quality improvement training, producing talented, committed staff who return to organisations that lack the structures needed to sustain or measure improvement. The result is predictable; pockets of brilliance but no consistent, system‑wide progress.

In 2017, the Bevan Commission published Achieving Profound and Sustainable Improvement in Quality in NHS Wales. It was widely welcomed by clinicians, managers, trade unions and frontline staff. Yet the Welsh Government agreed only to strengthen legislation, and not to mandate the formal, externally audited quality system that was the central recommendation.

The consequences of that decision are now impossible to ignore.

A system under strain and without the tools to improve

Recent analyses paint a stark picture. Wales faces:

• Record waiting lists, with long waits far exceeding those in England when adjusted for population
• A workforce crisis, marked by both shortages and poor planning, including newly trained doctors unable to secure posts in Wales
• Financial instability, with every health board breaching its statutory break‑even duty
• Mental health services under intense pressure, especially for children and young people
• System‑level weaknesses in productivity, accountability and leadership

These are not isolated failures. They are symptoms of a system that has never embedded a consistent, auditable approach to quality, one that survives leadership changes, budget cycles and political changes.

The Welsh Government’s 2023 Health and Care Quality Standards describe the characteristics of a quality management system in admirable detail. Yet they stop short of requiring organisations to have one. Wales has the language of quality, but not the machinery.

As WHO Director General Dr Tedros reminds us: “Quality is not a given. It takes vision, planning, investment, compassion, meticulous execution, and rigorous monitoring.” Wales has the vision. What it lacks is the execution and the monitoring and this can no longer be tolerated.

The case for mandating a quality standard

A formal, externally validated quality management system would:

• Provide consistency across all health boards and trusts
• Protect improvement work from the whims of organisational turnover
• Give staff the structure and confidence to innovate safely
• Support the systematic spread of proven innovations, including the work of Bevan Exemplars, whose impact is too often limited by system fragmentation
• Strengthen accountability without resorting to heavy‑handed, top‑down bureaucracy

Crucially, it would ensure that quality is not a slogan but a discipline.

The alternative – more central units, more dashboards, more top‑down oversight – risks repeating the mistakes of the past. Quality cannot be commanded into existence. It must be built, measured and continually improved.

A call for future‑proofing quality in Wales

If we are genuinely committed to quality, not as an aspiration but as a daily operational reality, then Wales must adopt a formal, externally audited quality management system for NHS Wales. This requires professional expertise, consistent standards and an approach embedded across every organisation.

This is not an exercise in bureaucracy. It is the essential infrastructure of safety, sustainability and public trust.

The question facing Wales now is clear: Are we prepared to build a health and care system where quality is assured, not assumed, and where we act as though health matters in every decision we make?

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.