Wait long enough, and everything comes back into fashion. Whether it’s flares, fondue or Fleetwood Mac, what once seemed passé could return to the cutting-edge of cool before you can say fidget spinner.
In public policy, too, there are ideas that come around again and again. For example, there’s prevention – or intervening early, nipping problems in the bud, nudging citizens towards good and healthy choices. However you describe it, this concept has regularly been talked of as the key to relieving pressure on over-stretched and under-funded public services and directing us to a more stable and sustainable social compact.
“Prevention is an idea that has its moment every few years – ever since the post-war period,” says Paul Cairney, professor of politics and public policy at the University of Stirling and co-author of the book Why isn’t Government Policy more Preventive? “It is a phrase that just keeps popping up for good reasons whenever any crisis arises.”
An emphasis on prevention is also politically attractive, appealing to parties on both the right and left. Preventative policy promises reductions in demand for public services, and therefore costs, and so sits well with fiscal conservatives, while the promise of improved life chances appeals to those seeking more radical social transformation and equality of outcome.
Ben Glover, head of social policy at the think tank Demos, says the discussion this time is different as it covers not just why preventative work is good but also why it hasn’t happened in the past.
“There’s a kind of sophistication to the debate at the moment, which is quite refreshing and relates a lot to wider public service reform conversations such as the need to make public services more relational and more integrated.”
One of the problems for policymakers is how to scale preventative policy across the wider public sector and fund it at a time when budgets are under immense strain. Politicians, of course, are always on the lookout for appealing solutions that deliver quick wins. Preventative approaches need time, long-term evaluation and follow up, running counter to short-term electoral cycles. No one is going to wait 30 years for a policy payoff, Cairney points out.
There is also, Glover says, a need for some honesty about the fairly hefty cost implications of taking a preventative approach. An unwillingness to be honest about trade-offs and downsides can hold policy agendas back, he argues.
“This has been a problem with prevention. It’s sometimes sold as a policy we can just shift money around [to pay for]. We need to invest more in universal and preventative services, but for the foreseeable future we’re going to need to staff acute services. So if you want to do this stuff it’s not going to come particularly cheaply.”
Cairney agrees that there has in the past been an unwillingness to be honest about costs of prevention. He points out that money set aside to fund preventative activity is often diverted to acute services when a crisis arises.
“People like the word ‘prevention’ but they don’t really know what they mean by it,” he adds.
“It’s an idiom that is ingrained – prevention is better than cure. Once governments realise what it means or how to make sense of it, that then presents them with problems about how that fits in with what they already do. And they tend not to have the willingness or capacity to do it properly.”
One of Demos’s big ideas to make this kind of policy more practical and achievable is the creation of a third category of public spending: Preventive Departmental Expenditure Limits, or PDEL, to sit alongside Revenue (RDEL) and Capital (CDEL). Altering the central government accounting framework in this way puts in place some ring-fencing and accountability around public spending for preventative measures, breaks the addiction to short-term fixes and sends an important signal about government priorities.
“Preventative spending has the greatest potential to deliver transformative results that can not only deliver the highest levels of impact but also make the greatest savings to the exchequer. However, we need to create a system of public spending decision-making that incentivises and supports these long-term investments,” Demos’s Revenue Capital Prevention paper, published with the Health Foundation, argues.
It draws an interesting parallel with the creation of capital spending as a category in 1998, which reflected the then-government’s priority of repairing the public realm, saying “PDEL is a simple, but powerful, idea that can lay the platform for reform of public services, bringing them into the 21st century.”
The involvement of the Health Foundation reflects the importance of prevention to health policy. The sector is in many ways the poster child for preventative policy and the most obvious place to look to see some good examples in action. From vaccination to smoking cessation interventions, preventative approaches have been shown to have profoundly beneficial outcomes for individuals and society.
Yet this sector still has work to do. In her review of integrated care systems (ICSs), published in April last year, former Labour health secretary Patricia Hewitt made the case that the NHS spends too much of its resources on treating acute illness and injury and not enough on prevention and wellbeing.
The go-to analogy is a river. Let health problems fester too long, drift too far downstream, and they become more difficult and expensive to deal with. Shift intervention upstream, then activity is cheaper and outcomes are better.
“Shifting the focus [of health activity] upstream is essential for improving population health and reducing pressure on our health and care system,” Hewitt wrote. “This will require a shift in resources – the share of total NHS budgets at ICS level going towards prevention should be increased by at least 1% over the next five years.”
Not all of what influences health outcomes is in the control of the NHS, of course. Wider quality-of-life factors such as housing, employment and access to green space all influence health. At the other end of the public-spending system, on the local authority front line, research is under way to look further upstream than Hewitt could.
Understanding investment in these social determinants of health is the focus of a two-year project being run by the Chartered Institute of Public Finance and Accountancy and the Health Foundation, which launched late last year.
Eleanor Roy, health and integration policy manager at CIPFA, welcomes what she describes as the emerging movement around preventative policy. The ideas being put forward are sensible, she says, and “it’s really hard to disagree with the logic”.
But she adds: “If we want to protect spending on prevention, or rebalance [away from] being reactive [towards] preventative spending, then we need to understand how much we are currently spending.
“To me, that’s a basic public financial-management question. If you want to set a budget, you need to know how much you’re currently spending. And that’s the one part of the equation that we don’t have.”
“If you want to set a budget, you need to know how much you’re currently spending. And that’s the one part of the equation that we don’t have”Eleanor Roy, CIPFA
Answering that question is the challenge CIPFA and the Health Foundation have set themselves. They will be working with a number of partner local authorities to track spending patterns on what might be called preventative activity, to help councils arrive at a better understanding of what they are doing now.
The researchers’ hope is that a model for tracking and evaluating preventative spending through financial data will be defined and then be applicable to other parts of the public sector. Another outcome of the project may be recommendations for changes to local government financial reporting requirements that seek to classify spending in new ways that better reflect preventative activity.
Cairney agrees that some additional financial reporting to track prevention is “essential”, although he suggest this should be layered on top of current reporting regimes, rather than replacing them. He highlights the conundrum between long-term, cross-party ambitions that enjoy widespread approval and short-term politics and performance management.
“The Scottish Government introduced [long-term targets] but also still contested elections based on short-termism. It’s relatively simple to set up long-term measures of success, but it’s not easy to incorporate or to connect them to short-term performance-management measures.”
Looking to the election, Cairney also points out that governments don’t rise and fall on how well they’re doing on preventative policy, especially at a time when hospitals and schools are failing, and if preventative policy is to enjoy political support it needs to be framed in a way the electorate can understand and get behind.
At Demos, Glover observes that both parties are talking about prevention in different ways, but it is unlikely to feature as a major plank of manifestos or as part of the political conversation around the election.
“The politics of this is potentially hard,” he says. “Politicians always have to have a particular message and way of engaging with the public. But under the bonnet, more can often be done.”
With some practical ideas underpinning it, maybe this time prevention won’t slip out of fashion.