Prevention is better than cure. It’s so obvious. A fence at the top of the cliff rather than an ambulance at the bottom. A no-brainer. But why is it so hard?
A question explored by the Scottish Parliament’s Finance Committee recently and the summary of the evidence gathered makes interesting reading. Is Scotland achieving the strategic shift to prevention imagined so brilliantly in the Christie Report?
There are some good tales to tell and I might mention some approaches we’re trying at the Big Lottery Fund too. Like investing more in small-scale community-led activity and setting aside funding for early intervention. Actions suggested by a detailed analysis of our past grant-making on a prevention / crisis spectrum – because if you want to shift the balance, you need to know where you are starting from in the first place.
But as well as describing what works I think it’s helpful to explore what holds change back, since over those practical barriers is the potential for greater progress. This is framed around the aim of freeing up public funding from the ‘end’ of the spectrum (crisis) to invest in the ‘start’ (prevention) as that’s the challenge our partners raise with me. I hear people saying:
- The imagination problem – activities to prevent or intervene early might be completely different from services to help people in crisis, we’re just not sure what to do, incremental improvement is more achievable than wholesale innovation
- The evaluation problem – we’ve got a great prevention idea but we can’t prove its impact on people’s lives or on reduced public services because it’s hard to count something not happening or the evidence will be ten years down the line
- The economics problem – we know what to do and it makes a difference but we can’t quantify the real financial savings, we can’t uncover what it costs to transport an older person from hospital or hold a court date for an offender, especially from outside the system
- The attribution problem – we know this saves real money but it’s not our money, savings from reducing reoffending are seen in the court system not the prison service, savings from better school meals are seen in health budgets not schools, ‘silo’ budgets don’t help
- The disinvestment problem – this saves money in theory but those savings only exist when we stop paying for something else, the building that’s closed due to lack of demand, the salary of the person delivering an unneeded crisis service, savings have consequences
- The contraction problem – and in the current context of reduced public funding, money saved is not necessarily money available for re-investment – even if we disinvest in the old service our overall budget is going down, we need to just save.
For me, strategies that have these problems in their sights are more likely to be successful.
But are there are a couple we can retire fairly quickly? I see plenty of ideas for preventative work in the activities of the third sector. And I think we are further down the evaluation road than we give ourselves credit, see for example Evaluation Support Scotland’s work on tracking protective characteristics.
Our efforts then need to focus more on the other barriers – economics, attribution, disinvestment and contraction – although these may be harder to crack.
Overall let’s also remember that saving public money shouldn’t be the only reason to focus on prevention: whether it costs more or less, helping out earlier means people live happier, healthier, longer lives.