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.
