The Acute Problem of Prevention: From ‘why’ to ‘how’

Prevention is not a new idea. In Andy Burnham’s first speech as Prime Minister, he pledged to build “a more preventative state”, and in Scotland it was a pillar of the 2011 Christie Commission. But the principle stretches back much further. Benjamin Franklin wrote that “an ounce of prevention is worth a pound of cure”; Erasmus argued that “prevention is better than cure”; and the Tao Te Ching urged us to “solve it before it happens”.

Whichever era or nation you come at it from, we’ve known for a very long time that prevention is the name of the game.

There’s the fundamental moral case, that avoiding a harm is better than trying to fix it after the fact. Then there’s the economic case, with proliferating evidence on how much return on investment or avoided cost preventative interventions generate.

None of that solves the question of how to actually prioritise prevention in the current landscape of limited budgets, capacity, political stability, and data.

But people are working on it. While acknowledging that it is only the first step on a long and complex process, the Prevention Unit at the Scottish Government has recently published a Prevention Toolkit, which gives decision-makers a concrete set of things they can try when thinking about how to work preventatively.

A particular focus has been developing and trialling the budget tagging tool, adapted from the method created by the Chartered Institute of Public Finance and Accountancy (CIPFA).

The pilot trial tagged £20-billion-worth of budget lines across seven Scottish Government portfolios, and found that more than half (52%) of the total planned spending analysed was for acute or responsive activity. Just over a quarter (28%) went into supporting basic operations.

There was, though, £3 billion (around 15%) of spend that could be classed as preventative. Within this preventative bucket, around £0.53 billion (18% of the planned preventative spend, or 2.7% of the planned total spend) was classed as primary prevention activity that ‘solves it before it happens’. The rest (82%) of the planned preventative spend was secondary or tertiary prevention, targeted at responding to problems after they’ve arisen.

That £3bn of spending on preventative activity – and especially the £532 million on primary preventative activity – is worth celebrating. For those of us who advocate for truly long-term approaches to governance and wellbeing, there is still a way to go. But this pilot is a promising signal: the first step is knowing where money is currently spent, and what improvement looks like.

The Prevention Unit has explicitly attempted to make the budget tagging tool and the others in the Toolkit practical to adopt, fitting them within existing structures and seeking alignment with other processes, including Treasury guidance. Offering an agreed definition of prevention and its sub-types helps to create shared understanding.

The opening attempt at outcomes tagging, and the considerations of evidence and evaluation, start to model how we will know where activities seek to make change and whether they work.

This all makes me hopeful that we’re moving beyond nice words and into the weeds of making things happen within a complex system. 

There is more to do. How will this land, for example, in a local authority’s already-stretched budget process? What about for the many third sector organisations whose preventative work is infrequently captured in or rewarded by official reporting? What would a community wealth building approach to a prevention toolkit look like?

Perhaps top of the list of questions for me is about how we shift spend and processes to work cross-departmentally and for long-term outcomes. We’ve got some suggestions at Carnegie UK for how you can do that – including through innovations like the Early Intervention Investment Fund in Victoria, Australia, which gets a brief reference in the Toolkit.

There are many things to iron out if we are to hurdle the implementation gap. But it’s worth a brief pause to appreciate that efforts are being made. As fellow travellers, instead of just pointing at potholes, we should be offering to help find fixes that serve the present and the future.