Senedd Manifesto 2026

The Senedd election on 7 May 2026 will bring significant changes to Wales’s political landscape, including a new voting system, revised constituencies and an expanded Senedd. Yet, for patients and NHS staff, the more pressing concern is meaningful reform of the health system itself. Services have never fully recovered from the impact of the COVID-19 pandemic, leaving patients facing long waits for care, and staff working under sustained pressure. These combined challenges make clear that longer-term, system-wide change is essential.

Findings from our 2025 UK Surgical Workforce Census show that patients in Wales are being directly affected by the pressures facing the surgical workforce. Welsh surgeons report higher levels of theatre access challenges, burnout and stress than colleagues elsewhere in the UK – pressures that reduce surgical capacity and contribute to longer waits for treatment. Although there have been some improvements, the size of the waiting lists and the length of waits risk becoming entrenched unless strategic investment is made to expand capacity and support the workforce that delivers care.

Regulatory gaps also continue to put patients at risk. Wales lacks sufficient safeguards for both cosmetic surgical and non-surgical procedures, leaving people vulnerable to inconsistent standards and unsafe practice in this growing industry. Persistently poor oral health among children is driving avoidable demand into secondary care, adding further pressure to services and the staff delivering them. At the same time, concerns around sexual misconduct in healthcare continue to impact staff safety, workplace culture and, ultimately, the quality of care patients receive.

To address these issues – and to improve outcomes for patients while supporting NHS staff – the Royal College of Surgeons of England sets out five key asks for the next Welsh Government.

1. Surgical Hub Implementation Plan

Ask

The next Welsh Government must put surgical hubs at the centre of its approach to reducing the waiting list backlog by developing and publishing a Surgical Hub Implementation Plan.

Measurement

Within the first year, the new Welsh Government should:

1. Establish a Surgical Hub Implementation Group bringing together NHS Wales organisations, clinical leads and Royal Colleges to determine locations and specialty focus for future hubs.

2. Establish a minimum of four hubs at existing sites.

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2. Long-term workforce strategy for health and social care

Ask

To secure the long-term sustainability of NHS services in Wales, the next Welsh Government must commit to a clear long-term workforce strategy for health and social care.

Measurement

  • Establish a Workforce Strategy Development Board within the first 100 days of taking office, with a clear remit to develop and publish a long-term workforce strategy by the end of 2027.
  • Bring together NHS Wales organisations, professional groups and workforce experts, with Health Education and Improvement Wales (HEIW) supporting development and delivery through its expertise and data.
  • Base the strategy on clear, credible workforce projections for all staff groups, so future staffing needs are properly understood and planned for.

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3. Improving safety in cosmetic surgery

Ask

The next Welsh Government must ensure a licensing scheme is in place for non-surgical cosmetic procedures, and that surgical cosmetic procedures are only carried out by surgeons who are Cosmetic Surgery Board Certified.

Measurement

  • Within the first year of office, the next Welsh Government must publish a detailed roadmap and legislative timetable for strengthening the regulation of both non-surgical and surgical cosmetic procedures in Wales. This plan should set out clear milestones for consultation, legislation and enforcement.
  • If UK Government legislation currently being developed will not apply to Wales, the next Welsh Government must introduce Welsh legislation within the first two years of the Senedd term to establish a comprehensive licensing scheme for cosmetic procedures, either through new primary legislation or by strengthening existing licensing rules for special procedures.

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4. Strengthen reporting mechanisms to tackle sexual misconduct in healthcare

Ask

The next Welsh Government must:

  • Strengthen reporting and transparency around sexual misconduct and harassment by building on the new NHS Wales Anti-Sexual Harassment Policy;
  • Improve data collection by including specific questions in the NHS Wales Staff Survey on staff confidence in reporting sexual misconduct and harassment, and in the action taken when concerns are raised;
  • Require regular publication of anonymised data on the number of sexual misconduct and harassment incidents across Health Boards, and the actions taken in response;
  • Hold Health Boards to account by requiring them to set out in their Annual Reports how they review this data and what steps they have taken to improve behaviour and workplace culture as a result.

Measurement

  • Work with Health Education and Improvement Wales (HEIW) to include additional questions on sexual misconduct and reporting confidence in the NHS Wales Staff Survey due in October 2026.
  • Enable Statistics for Wales to collect and publish Wales-wide and Health Board-specific data on sexual misconduct and harassment incidents.
  • From 2026/27 onward, require Health Board Annual Reports to clearly set out the actions taken following review of this data.

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5. Reclaiming Wales’ place in leading oral health improvements

Ask

The next Welsh Government must establish a one-off, expert-led review of the Designed to Smile programme to understand why progress in reducing dental decay in young children has stagnated over the last decade.

Measurement

  • Within the first year of office, establish this review to assess the impact of Designed to Smile, identify reasons why progress has stalled, and set out what targeted action is needed. The Faculty of Dental Surgery (FDS) of the Royal College of Surgeons of England should be included in this review.
  • Building on the findings of the review, strengthen the programme’s monitoring arrangements so they track outcomes, such as reductions in dental decay, improvements in access, and consistency of delivery across Health Boards, rather than solely counting programme activities.

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Further detail on our manifesto priorities

1. Surgical Hub Implementation Plan

Wales is falling behind in the development of hubs

Surgical hubs have been adopted across the UK to separate planned care from emergency pressures and support elective recovery. In England, this model has been scaled rapidly: as of January 2026, a total of 124 surgical hubs have been established. This represents a significant expansion from 108 hubs in September 2024, with earlier plans projecting growth to 134 hubs by the end of 2025.

The model has also been pursued in Northern Ireland, where the Executive has driven the expansion of surgical hubs as part of wider elective reform. Currently, six hubs, operating in various forms, provide surgical services to a population of approximately 1.9 million.

In Wales, with a population of 3.2 million, the Welsh Government has recognised the importance of separating planned care from emergency care. Its Elective Care Recovery Plan explicitly acknowledges this, stating:

“We want to make services more efficient and reduce cancellations by creating dedicated surgical facilities and separating planned care from urgent and emergency care.”

Despite this recognition, progress has been limited and slow.

Wales currently has one operational surgical hub at Neath Port Talbot Hospital. Two further hubs – an orthopaedic hub in Llandudno and another in Llantrisant Health Park – are still in development and have faced repeated delays. 

The Llandudno hub, originally due to open in early 2025, is now expected to be operational in spring 2026. Development of the Llantrisant hub has also been sluggish, with its opening not anticipated until 2027.

The current approach has missed the opportunity to use existing sites as hub locations

Our 2022 report, The Case for Surgical Hubs, set out three main models:

  1. Integrated hub (‘hub within a hospital’): ring-fenced areas within existing hospitals.
  2. Stand-alone hub: separate sites carrying out less complex surgery.
  3. Specialist surgical hubs or hospitals: stand-alone facilities providing specialist surgery.

In Wales, the current focus has been on building new surgical hubs. However, hubs can take different forms. They do not need to be new buildings, and they do not always require major investment. There is a clear opportunity to expand the number of surgical hubs by making better use of existing sites.

This issue is reflected in our 2025 UK Surgical Workforce Census. It found that 60.5% of respondents in Wales see access to theatre space as a major challenge. This was higher than any other part of the UK, underlining the particularly difficult position faced by surgeons in Wales.

The next Welsh Government needs to set out a clear Surgical Hub Implementation Plan to drive delivery

While there are practical challenges in setting up more surgical hubs, the main barrier is the lack of a clear top-down strategy from Welsh Government.

Such a plan is needed to provide clear leadership to the health service by:

  • setting a clear vision for ring-fencing planned care;
  • identifying existing sites that can be used as surgical hubs, avoiding the cost and delays associated with new builds;
  • identifying where hubs should be specialty-specific, and how this will work in practice;
  • embedding clinical expertise through Royal College representation on the Implementation Board;
  • supporting partnership working between Health Boards to deliver care on a regional basis;
  • setting firm timescales to bring hubs into operation quickly and prevent further treatment delays.

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2. Long-term workforce strategy for health and social care

The current approach to workforce planning has been fragmented and piecemeal

Responsibility has largely been placed on individual parts of the system to plan their own workforce needs. Where system-wide planning has taken place, it has tended to focus on individual professions rather than taking a holistic approach towards the workforce. A whole-system approach to workforce planning would address the current situation, where planning is carried out in isolated parts rather than across the whole service.

Health Education and Improvement Wales’ (HEIW) 2020 Workforce Strategy for Health and Social Care outlines broad ambitions for the system, to be achieved by 2030. However, it does not provide the long-term evaluation and projection of service user needs to enable clear numbers of workforce supply to be identified. Underneath this, HEIW have developed a number of individual workforce plans for specific areas – including primary care, diagnostics, and pharmacy – but not one single integrated plan. Surgery is not mentioned in either the 2020 Strategy, neither is it focused on as an individual plan.

Long-term consideration of secondary care workforce numbers is needed given the persistently high vacancy rates in these professions. From 2023 until June 2025, vacancy levels for the medical and dental staff group were the highest in Wales. Although the rate has fallen from a peak of 10.7% in June 2023, at 7.9% in September 2025, vacancies are the second highest of any staff group – and well above the all-staff vacancy rate of 5.7%.

While strengthening primary care is essential to managing future demand, reducing the waiting list backlog – and keeping it down – depends on a sustainable secondary care workforce, regardless of the ongoing shift of care from hospitals into the community. The continuing challenge of access to NHS dentistry also requires a long-term strategic solution, identifying clear numbers of workforce supply to meet demand to enable targeted policy solutions to be developed.

There is also a growing risk that training supply will not be sufficient to meet future service needs. Under HEIW’s latest Education and Training Plan, the number of secondary care and specialty training posts for 2025-26 was initially set at 42 but later reduced to just 21.

The 2025 Audit Wales report, Addressing Workforce Challenges in NHS Wales, highlighted that affordability pressures, limited placement capacity and falling application numbers are constraining key training pipelines. The report also found that commissioned training places are insufficient to meet expected service demand in several clinical specialties, including Urology, Vascular, Ophthalmology, and Cardiology. While the MAG Report concluded that existing staffing levels are sufficient to allow an expansion of the surgical hub model, a dedicated long-term focus is needed to understand and plan for the workforce required to meet rising demand in the years ahead.

Ongoing pressures demand clear direction

Since HEIW published its workforce strategy, the health and care system has faced major and growing pressures. These include the lasting impact of the COVID-19 pandemic, changing patterns of international recruitment, and an increasingly ageing population. Together, these trends are placing significant strain on workforce morale and long-term sustainability. Wales cannot afford not to have a long-term workforce strategy, not only to manage these pressures, but to meet them head on.

The health and social care workforce is NHS Wales’ greatest asset and its most important investment. Securing a sustainable workforce is not just about having enough staff; it is also about creating the right working environment. Investment in wellbeing and morale is essential for recruitment and retention, and for delivering high-quality patient care. Our 2025 UK Surgical Workforce Census found that 63.7% of respondents in Wales reported burnout and stress as a major issue – the highest rate of any UK nation. The next Welsh Government must ensure both the current and future workforce are supported, including through more flexible working options and improvements to both the physical and cultural working environment.

The wider UK context is also evolving. The UK Government is developing a 10 Year Health Plan for NHS England workforce planning, and Wales cannot risk falling behind. Cross-border healthcare is already a reality for some Welsh patients and, without a clear plan to grow the workforce across a wider range of surgical specialties, this problem will worsen. Access to timely treatment cannot become dependent on postcode. Wales needs a clear, homegrown strategy to protect patients and secure the future sustainability of NHS services.

The next Welsh Government must provide clear leadership to address short-termism

The National Workforce Implementation Plan (2023) highlighted the problem of short-term thinking. It focused heavily on reducing agency staffing, without setting out how the underlying causes, including gaps in workforce supply and infrastructure, would be addressed to deliver long-term sustainability.

Responsibility for managing workforce pressures has largely fallen to HEIW or individual Health Boards. In its 2024 Workforce Strategy progress update, HEIW acknowledged that its workforce plans can realistically look only two to three years ahead, which limits their focus to incremental improvement rather than long-term, systemwide change. Health Boards, meanwhile, can only plan within the boundaries of the wider national strategy – or the absence of one. Expecting them to shoulder this responsibility is unrealistic, particularly when their own planning capacity is already stretched. This is where national leadership is required, and where the next Welsh Government must step in to provide long-term, systemwide change.

We are not the only voice calling for a long-term workforce strategy for Wales. There is a growing consensus in the sector that this is needed, with both HEIW and Audit Wales highlighting the need for a longer-term approach. However, given that past strategies have overlooked secondary care, it is vital that any new workforce strategy:

  • involves clinical voices directly in its development;
  • avoid silos by supporting better integration between secondary and primary care, including opportunities to develop prehabilitation and rehabilitation services around surgical care;
  • is underpinned by clear, credible workforce numbers across all staff groups, including consultant surgeons, dental surgeons, SAS doctors, locally employed doctors (LEDs) and resident doctors in surgery;
  • commissions sufficient training places to meet future service demand;
  • supports the current and future workforce through strong wellbeing policies that improve both the physical and cultural working environment.

Without this shift, workforce planning in Wales will remain reactive rather than strategic, and the long-term sustainability of NHS services will continue to be at risk.

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3. Improving safety in cosmetic surgery

Wales risks falling behind in licensing non-surgical cosmetic procedures

In March 2026, the Scottish Government passed legislation to improve the safety of cosmetic procedures whereby:

  • procedures including injectables like Botox and dermal fillers will have to be supervised by a qualified health care professional in a setting regulated by Healthcare Improvement Scotland (HIS).
  • procedures including breast and buttock augmentation will have to be performed by a qualified healthcare professional in an HIS-regulated setting.

The UK Government has also announced several proposals on cosmetic procedures. 

  • Only qualified healthcare professionals will be able to perform the riskiest procedures such as non-surgical BBLs.
  • These procedures must be undertaken by organisations that are registered with the Care Quality Commission (CQC).
  • Procedures involving Botox or fillers will now become properly licenced through a new local authority licensing scheme.
  • It will be illegal to administer regulated and licensed procedures to young people under the age of 18 unless it has been authorised by a clinician.
  • Practitioners will need to meet strict standards on education, training, infection control, patient safety, and insurance before they can operate legally, under a licensing scheme run by local authorities. 

The UK Government will launch a public consultation on these proposals in 2026, marking a crucial step towards closing this regulatory gap.

Wales has already shown it can act to regulate procedures that may put people at risk. In 2024, a licensing scheme was introduced for acupuncture, body piercing, electrolysis and tattooing. If the UK Government’s proposals do not cover Wales, the next Welsh Government must build on the existing special procedures licensing scheme. This should ensure that non-surgical cosmetic procedures are subject to licensing, and that surgical cosmetic procedures can only be carried out by surgeons who are Cosmetic Surgery Board Certified. Wales cannot be allowed to become the only country on mainland UK where unlicensed cosmetic procedures are permitted to take place.

Wales must play its role in closing cosmetic surgery regulatory loopholes

It is vital that surgical cosmetic procedures, which carry the highest risk of complications, are regulated at the same time as non-surgical procedures. Failing to do so risks creating a significant loophole where cosmetic surgery remains unregulated. This inconsistency could undermine patient safety and public trust.

All high-risk cosmetic procedures, including surgical interventions, should be regulated consistently. These procedures should be restricted to surgeons who have undergone appropriate training and hold relevant Board Certification, ensuring the highest standards of care and accountability.

There is no specialty in cosmetic or aesthetic surgery and no regulation on who can perform it. Currently, the only requirement is to be on the Medical Register, not the Specialist Register. Highly invasive cosmetic operations – breast implants or reduction, rhinoplasty, facelifts, liposuction – can therefore be carried out by a doctor who has had no formal surgical training.

In no other area of medical practice would we allow patients to undergo invasive surgery or high-risk surgical procedures by anyone other than a surgeon with the appropriate training. The powers to address this through regulation resides with the UK Government, but the next Welsh Government has a role to play – collaborating with Westminster to ensure that cosmetic surgery is restricted to surgeons who have undergone appropriate training and hold relevant Board certification.

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4. Strengthen reporting mechanisms to tackle sexual misconduct in healthcare

In 2023, the Working Party on Sexual Misconduct in Surgery (WPSMS) published Breaking the Silence: Addressing Sexual Misconduct in Healthcare, the first comprehensive analysis of sexual misconduct within the surgical workforce. The report exposed the widespread nature of the problem and set out clear recommendations covering policy, education, workplace culture and data collection.

There has been some progress on this issue since the report’s publication. The General Medical Council has strengthened its expectations by reinforcing a duty to act on sexual misconduct in its updated Good Medical Practice and the guidance Maintaining Personal and Professional Boundaries.

As a College, we have also reflected on our own responsibilities. In 2024, we introduced a new Code of Conduct setting clear expectations for staff, members and non-members holding appointed or elected roles, with sexual misconduct, harassment and bullying explicitly defined as breaches of that Code. In 2025, we published Turning the Tide, which set out eight priority actions to improve the reporting of sexual misconduct in NHS England.

While the recommendations in Breaking the Silence focused on England, the WPSMS was clear that sexual misconduct must be treated as a UK-wide issue, to ensure parity for all healthcare workers. There are already areas of alignment across the UK. In October 2024, the Worker Protection (Amendment of Equality Act 2010) Act 2023 came into force, applying to Welsh employers. This legislation places a legal duty on employers, including NHS Wales organisations, to take reasonable steps to prevent sexual harassment. Where employers fail to meet this duty, the Equality and Human Rights Commission can take enforcement action, and employment tribunals have the power to increase compensation awards by up to 25%.

Sexual misconduct within Welsh healthcare

Our 2025 UK Surgical Workforce Census found that almost one in five Welsh respondents identified workplace culture and environment – including bullying and harassment – as a major challenge. The NHS Wales Staff Survey 2024 reported just over 4% of respondents had experienced unwanted sexual behaviour from staff or colleagues. While this may appear low, it still represents just under 1,000 individuals. This figure must be seen in the context of a survey response rate of only just over 20% of NHS Wales staff. The true scale of sexual misconduct across the workforce is therefore likely to be higher and remains unclear.

Despite increased attention on this issue – including the work of the Working Party on Sexual Misconduct in Surgery and the Royal College of Surgeons of England, alongside clinicians speaking openly about their experiences – many staff still lack confidence in reporting systems. This is reflected in the same NHS Wales Staff Survey, where almost a quarter of respondents (24.6%) disagreed with the statement: “If I spoke up about something that concerned me, I am confident my organisation would address my concern.”

Sexual misconduct also poses a serious risk to the future workforce. In November 2025, the BMA published findings from a UK-wide survey on sexism and sexual violence experienced by medical students. It found that 41% of female respondents and 19% of male respondents had experienced sexual harassment or assault at university. Of those who reported incidents, three-quarters said they were not, or were only partly, satisfied with the outcome.

Building on NHS Wales policy through strengthening reporting mechanisms

In October 2025, the new NHS Wales Anti-Sexual Harassment Policy came into effect, enshrining guiding principles including:

  • Creating working environments that are open, safe and do not tolerate inappropriate behaviour.
  • Providing confidential, accessible and non-retaliatory reporting mechanisms for individuals to raise concerns about sexual harassment.
  • Ensuring Executive Teams regularly review data relating to sexual misconduct and that lessons are learnt and changes in practices are made to improve sexual safety in the workplace. 

The next Welsh Government must strengthen this policy by fixing the reporting systems on which its success depends. As Breaking the Silence made clear, “current reporting mechanisms are not clear and not trusted, and there is wide variation in the competency of those carrying out investigations.” A policy cannot succeed if the systems designed to give healthcare workers a voice are outdated, unclear, or ineffective.

If the policy has been refreshed, the processes that support it must be reviewed and improved as well. A strong policy without the structures needed to put it into practice will fail. To understand how well current reporting mechanisms are working, better data is needed. This starts with improving data collection by expanding the number of targeted questions on sexual misconduct and harassment in the NHS Wales Staff Survey. These should cover the confidence of staff to report these incidents, and staff confidence in their organisation's response to these incidents. It should also include the regular publication of anonymised data, at both Wales-wide and Health Board level, showing the number of reported incidents and the action taken in response.

To demonstrate that reporting systems are effective, the next Welsh Government should require Health Boards to set out in their Annual Reports how they review this data and what changes have been made as a result. This should clearly explain what steps have been taken to improve behaviour, workplace culture and staff confidence in reporting concerns.

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5. Reclaiming Wales’ place in leading oral health improvements

Designed to Smile

With the introduction of the Designed to Smile programme in 2009, Wales showed early leadership by adopting a coordinated, prevention focused approach to childhood dental decay. The programme aims to improve oral health among children ages 0-7 by:

  • providing toothbrushes, fluoride toothpaste and oral health advice to families;
  • encouraging dental attendance before a child’s first birthday;
  • delivering supervised daily toothbrushing in nurseries and primary schools;
  • applying fluoride varnish twice a year.

Since its introduction, Designed to Smile contributed to reductions in childhood dental decay, particularly in deprived communities. However, despite these early gains, outcomes for children’s oral health have failed to improve since the mid-2010s, and high levels of decay persist. This raises serious questions about whether the programme, in its current form, is delivering the impact intended and what needs to change to improve outcomes.

Dental decay among children in Wales remains a serious concern

Dental decay is a preventable disease, yet progress in improving children’s oral health in Wales has stalled for almost a decade. In 2022-2023, nearly one in three five-year-olds (32.4%) in Wales had experience of dental decay. While this represents a clear improvement from 2007-08, when almost half (47.6%) of five-year-olds in Wales had experience of dental decay, there has been no meaningful progress since 2015. An expert-led review is needed to understand why progress has stalled.

For many children, poor oral health is not just a clinical issue but a daily lived experience. Close to a fifth of children in Wales report pain, difficulty eating, disrupted sleep, and emotional or family stress. These impacts fall disproportionately on children in the most deprived communities, where dental decay is both more common and more severe. This entrenches health inequalities early in life and increases demand for treatment across the NHS.

Poor oral health also drives pressure on services. Welsh data show that  more than four in five referrals for hospital-based dental treatment in children are due to tooth decay, including referrals for dental extractions under general anaesthetic (GA). This highlights both the urgent need for more effective early intervention, and the missed opportunity to reduce demand on secondary care.

From leading to lagging

Across the UK, children’s oral health outcomes have improved more quickly where prevention programmes are supported by strong monitoring, evaluation and delivery. In England, 23.7% of five-year-olds experienced dental decay, compared with 32.4% in Wales. This gap persists despite Wales introducing similar policies, including:

Scotland’s Childsmile programme provides a clear contrast. Like Designed to Smile, it combines supervised toothbrushing, fluoride varnish application, and early years engagement. However, Scotland has also embedded national monitoring and evaluation. As a result, dental decay among five-year-olds fell from 42% in 2007–08 to just over 25% in 2022–23 during the same period in which progress in Wales stalled.

The persistence of poorer outcomes in Wales, despite similar policy tools, makes clear that Designed to Smile now requires independent scrutiny.

Wales must carry out an expert-led review of the Designed to Smile programme

The lack of improvement in children’s oral health outcomes in Wales since 2015-2016 is a clear warning sign. While Designed to Smile remains a positive intervention, current decay rates – particularly in deprived communities – demonstrate that the programme in its current format is not working.

While annual reports of the programme are being produced, these currently focus on inputs into the programme rather than the impact these are having. It is therefore impossible to understand how beneficial these individual interventions are, and broader than this, how the programme itself needs to adapt.

The next Welsh Government must act decisively by enacting an expert-led review of Designed to Smile within its first year in office, and use its findings to reset the approach. This review should:

  • establish a clear understanding of why progress in improving children’s oral health has stalled, and what changes are required to restart improvement;
  • identify what is working well and should be expanded, and where delivery is inconsistent or ineffective across Health Boards and geographical areas;
  • test whether the programme remains aligned with current population needs, including changing patterns of access to NHS dentistry or pressures across primary and secondary care;
  • provide the evidence to support targeted action, focusing resources on communities with the highest burden of disease;
  • use the review findings, and subsequent adaptations to the programme, to pivot the annual monitoring reports towards a greater focus on the impact of its activities, rather than the inputs themselves. This should form a feedback loop to inform planning and health improvement.

The FDS brings a unique perspective across prevention, primary care, and secondary care dental pathways, as well as deep insight into workforce pressures and patient outcomes. Involving FDS in this review would strengthen understanding of how preventive programmes affect NHS dental services, continuity of care, workforce capacity and demand for hospital-based treatment.

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