As pressures intensify across the health system, how can Wales shift the balance of care toward prevention and community‑based support?
The NHS in Wales is at a tipping point. Rising chronic illness, more people living with multiple long‑term conditions, and fewer years spent in good health mean demand for hospital care now far exceeds capacity. Increasing hospital funding alone won’t solve the problem. Wales needs a fundamental shift towards a system that delivers more care closer to home and prioritises prevention.
This ‘left shift’ has been a long-standing ambition, central to Welsh Government policy and widely supported by stakeholders. Yet progress has been slow, held back by acute pressures, short-term priorities, and funding models that fail to incentivise prevention.
Why transformation is needed
The current NHS model is being overwhelmed by types of need it was not designed to meet. Acute hospitals were set up to treat people requiring urgent, short‑term, or specialist medical care. However, much of today’s pressure stems from chronic, often preventable, conditions such as cardiovascular disease, diabetes, respiratory illnesses, and frailty - conditions that develop over many years and require ongoing, coordinated management.
- 48% of adults in Wales live with at least one chronic or long‑term condition, and 20% are living with two or more.
- Prevalence of long‑term conditions is projected to rise. This is partly driven by an ageing population, with age a key risk factor for many conditions. Complex multimorbidity (four or more long-term conditions) is expected to almost double by 2035.
- Health inequalities are entrenched and widening. Men in Wales' most deprived areas spend almost 20 years less in good health than those in the least deprived, and women spend 25 years less.
When people’s conditions worsen, hospitals end up treating problems that might have been prevented with earlier support. This absorbs capacity, disrupts planned care, and contributes to longer hospital stays and delayed discharges, adding further strain to an already pressured system.
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Case in focus: Type 2 diabetes 220,000 people in Wales live with diabetes (around 90% Type 2). By 2035, numbers are projected to increase by 48,000 - bringing the total to about 1 in every 11 adults. Deprivation is a factor in diabetes risk and prevalence. In 2019-20, over one in five hospital admissions for people aged 65+ involved diabetes as a primary or secondary diagnosis. The direct cost of diabetes in the UK was estimated to be £10.7bn in 2021-22, with over 60% of this spending attributed to managing complications. Evidence suggests that over half of type 2 diabetes cases could be prevented, for example through earlier identification of risk and targeted support to help people adopt healthier lifestyles. |
What is a left shift?
In health policy, a left shift refers to moving care upstream - through prevention, early intervention, and stronger primary and community‑based support – and reducing reliance on costly hospital-based care. This approach is central to the Welsh Government’s long‑term plan for health and social care, A Healthier Wales (2018), which set out a vision for seamless, people‑centred services delivered closer to home, with an emphasis on keeping people healthy and independent.
In practice, this shift involves supporting people in their own communities through, for example, integrated GP and community teams, better joined‑up health and social care, and digital tools that help people manage their health from home. It also depends on multi‑agency partnerships across housing, social care, community organisations, and the third sector.
Barriers to change
Despite broad agreement that a left shift is vital for the long-term sustainability of the NHS, Wales has struggled to move care from hospitals to community and preventative services at pace. This is due to a combination of entrenched system pressures and structural barriers.
In addition to the growing burden of chronic illness, key barriers include:
- Acute pressures and post‑pandemic backlogs keep the NHS focused on immediate hospital activity, reinforced by political and media attention on issues such as hospital waiting times.
- Workforce shortages and fragmented, siloed roles hinder development of the multidisciplinary teams needed to deliver community‑based, preventative care.
- Limited community and social care capacity delays discharge and slows patient flow, constraining the system’s ability to move activity out of hospital.
- Annual budgets and performance frameworks incentivise acute activity, while preventative and community services - where benefits emerge over years and span organisational boundaries - struggle to secure long‑term, stable investment.
A core challenge is shifting resources away from secondary care without destabilising essential hospital services. For example, while welcoming the expansion of community optometry services, the Sixth Senedd Health and Social Care Committee cautioned that diverting attention or investment away from secondary care ophthalmology risks exacerbating long waits, with serious consequences for people at risk of preventable sight loss.
Successful system transformation also relies on strong public buy‑in, with early and meaningful engagement at national and local levels key to securing community input and support for changes in how and where services are delivered.
International evidence: what can Wales learn from elsewhere?
International experience shows that these barriers are not unique to Wales, but also that progress is possible with sustained investment and system‑wide commitment. While health systems differ across countries, these examples offer insights that are relevant to the Welsh context.
Public Health Wales’ 2023 horizon‑scanning report points to countries such as Brazil and Slovenia, where community‑embedded prevention, social prescribing, joint training, and cross‑sector collaboration have helped reduce pressure on hospitals.
Further lessons from the Nuffield Trust’s 2025 From Hospital to Community report - drawing on Denmark and Ireland - show that successful left shift strategies depend on cross‑party consensus, long‑term planning, and strengthening the community workforce.
Crucially, community services in these countries have been strengthened in parallel rather than funded through cuts to hospital budgets, recognising that a reduction in hospital activity must be matched by sufficient community capacity to absorb greater demand.
Action beyond the NHS is required
A left shift cannot succeed if poor‑quality housing, insecure work, or social isolation continue to undermine people’s health. The NHS is a vital part of the system, but the factors that most influence health lie beyond healthcare.
The wider determinants of health are the social, cultural, economic, environmental, and structural conditions that influence people’s lives - including education, fair work, income, housing, transport, and the natural and built environment. These determinants drive health outcomes and inequalities to a far greater extent than healthcare alone, and are at the heart of Wales’ long‑term approach to improving wellbeing, including the Well‑being of Future Generations Act.
Evidence from the Health Foundation, BMJ Commission, and the King’s Fund consistently shows that the NHS cannot, by itself, deliver major improvements in population health. Lasting progress depends on coordinated cross‑government and cross‑sector action to improve the conditions in which people live, reducing avoidable demand on health and care services, and enabling people to thrive in their communities.
From vision to implementation
Wales has long recognised the need to shift care towards prevention, earlier intervention, and community support. The ambition is clear, and many of the building blocks for a more sustainable health and care system are already in place. Delivering the left shift will require stable long‑term investment in community services, aligned incentives for prevention, and a workforce model designed around continuity and proactive care. The question now is not whether Wales can afford to change, but whether it can afford not to.
Article by Philippa Watkins, Senedd Research, Welsh Parliament
