Prevention Watch August 2025
Prevention Watch is a regular Scottish Health Equity Research Unit (SHERU) briefing that looks at prevention as a means of public service delivery to reduce health inequalities in Scotland.
Responses to the population health framework and public sector reform strategy
In June 2025, the Scottish Government published its long-awaited Population Health Framework. Our full response for those who haven’t seen it yet is here. In summary, there is a strong vision on prevention backed up by strong evidence on why it is needed. However, we felt little sense of the rest of government coming up behind in support of the vision. New commitments made in the framework were downstream policies within the health sector itself and aren’t coming from upstream policy areas like housing, early years or social security.
Another strategy document, but one that did feel a bit different, was the Public Service Reform Strategy released just a couple of days after the Population Health Framework.
Our colleagues at the Fraser of Allander Institute provided a summary of their thoughts on the strategy shortly after it was released, the most eye catching of which was the commitment to “measure preventative spend by Government and track that the proportion of spend on prevention increases and the resultant spend on acute/crisis decreases” (FAI view: sounds good but much more detail required).
Off the back of these strategies, Public Health Scotland recently convened a round table to bring together those with an interest in defining and measuring prevention in relation to health – the latter relating specifically to the commitment made in the Public Service Reform Strategy. It’s clear that there is a lot of appetite find a way to do this, but no one size fits all solution that would provide a neat summation of the fiscal implications of prevention in Scotland. It is great that Public Health Scotland are convening stakeholders to try and move this forward, and a broad range of views will be required to find the right way forward. We are keen to think about where our own analytical expertise, along with colleagues at the Fraser of Allander Institute, can add value.
As well as technical solutions, we were pleased to see recognition in the Public Service Reform strategy of the culture change needed across government, including the need to think about accountability. It spoke about the need to establish (i.e. support and require) joint working. We think this is critical for health inequalities where governance and accountability for population health outcomes remain rooted in the health portfolio, and not within areas that have the necessary levers on socioeconomic drivers (e.g. housing, employment, social security). Collaboration between officials can work well if incentives are well aligned, but if there are tensions or other policy priorities that are taking precedent elsewhere, collaboration can be limited to rebadging existing policies or strategies rather than co-producing a new or different approach. We admire the ambition of the Public Service Reform Strategy, but implementing these changes will perhaps require a rethink on who is held accountable for it being a success.
England’s 10-year health plan
Other parts of the UK have also been setting out long-term plans to improve health outcomes.
In July, England published Fit for the Future: The 10 Year Health Plan for England to address issues with England’s NHS. The majority of the plan discusses access to health care and efficiencies in the NHS system itself. However, prevention is discussed extensively within the plan:
“We will achieve our goals by harnessing a huge cross-societal energy on prevention. We will work with businesses, employers, investors, local authorities and mayors to create a healthier country together.”
Healthcare is a devolved power, meaning that any changes around the NHS in the 10-year health plan do not apply in Scotland. Changes in health service funding, however, would affect the amount of budget resources that are allocated to the devolved nations. Additionally, a joined-up policy approach in England should include upstream preventative policies, which could impact people here in Scotland if they related to reserved areas of policy.
There are some links made to upstream factors, such as reducing damp and mould in rental housing, addressing fuel poverty and providing more free school meals (which frees up cash for families). There is also no doubt that the authors of this paper (or at least this part of the report) understand that health is mainly influenced by factors outwith healthcare:
“So much of what determines our health and wellbeing has little to do with the health service. The roots of sickness too often lie in poverty, poor housing, poor education, poor work and poor access to the things that make life worth living like culture, sport and recreation.”
It can be difficult to assess how credible strategies like this are from afar, given its very easy to write down on paper things that have no bearing on reality. The Health Foundation, who are much closer to the English health system, have been quite critical regarding its potential for a shift to prevention. A recent blog on the subject stated that there was relatively little that amounts to a systems change approach with prevention:
“It is ultimately a plan for the NHS, not a plan for improving the health of the nation through a more fundamental preventative shift. Its focus is on mitigating the consequences of sickness rather than tackling the underlying drivers and introducing enabling structures and mechanisms to prevent ill health.”
Scrapping the two-child limit in Scotland
In June, Social Justice Secretary Shirley-Anne Somerville announced the start date for plans to counteract the “two-child limit,” which is a policy wherein families with more than two children are not entitled to additional Universal Credit benefits. Universal Credit policy is a reserved power and this policy has been in place since 2017.
The government previously committed to mitigating the limit in 2026/27, and in June, announced that the two-child limit payment would begin accepting applications in March 2026.
This payment will be a monthly payment matching the universal credit child element, at £292.81 per eligible child. The payment will be delivered by Social Security Scotland.
Modelling from the FAI showed that this policy could cost around £130 million in the first year, increasing as time goes on. This figure is slightly more conservative than the Scottish Fiscal Commission’s estimation that it could cost £155 million in the 2026/27 financial year. This difference is largely due to differences in modelling approaches, with the precise cost as yet unknown.
FAI analysis also found that it will keep approximately 15,000 children out of relative poverty, and the fiscal commission further found that around 43,000 children will benefit financially in some way.
This is a good example of a concrete upstream measure that should improve the living standards of children in larger families and their health outcomes. We note, with some disappointment, that the Two Child Limit announcement and the Population Health Framework came on the same day, in consecutive statements to Parliament, yet with no acknowledgement of their interconnectedness in terms of potential outcomes.
Draft environment strategy consultations
The Scottish Government is taking consultations on a new environmental strategy for Scotland, following the one from 2020. Thankfully, in this area, there is clear joining up with health being a key consideration for the draft strategy.
Earlier in the year, we published a report exploring environmental inequality, specifically looking at air pollution and inequality in Scotland. In this report, we found that if the government wants to consider inequality in developing future air quality framework, they need to make sure that they can measure it and that they are aware of where significant inequalities lie. We found that there is a variety of inequalities in pollutant exposure across Scotland, with minority ethnic communities experiencing notably higher levels of pollution on average.
Additionally, while the most deprived communities are not necessarily the most polluted parts of the country, they are the most likely to experience the worst outcomes related to pollution. This means that a targeted approach to environmental policy is likely necessary to reduce these inequalities.
However, outside of conducting impact assessments, the Scottish Government and local authorities do not appear to track environmental inequalities, and there is not targeted policy towards deprived communities.
Beyond just pollution levels, environmental strategies have the ability to impact health through other means, including community well-being (such as access to green space), transport, and employment. There are notable environmental inequalities across all of these areas. Deprived communities are less likely to live near or visit green spaces. Environmental policy also impacts the way that communities are accessed and connected through transport, which people in deprived areas less likely to be able to afford. Employment is also a significant consideration: as the economy moves towards renewable energy, the government needs to ensure that people working in polluting industries are able to maintain good quality employment.