By Professor Ewan B Macdonald CBE, Bevan Commissioner
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?
About the Author, Professor Ewan B Macdonald CBE
Professor Ewan B Macdonald CBE is a Bevan Commissioner and a leading authority in occupational and environmental health. He is Head of the Healthy Working Lives Group at the University of Glasgow and has during his career created four successful ISO Registered Occupational Health and Return to Work Services.
