Prevention Watch – January 2025

In this edition we cover:

• Public Health Scotland’s typology of prevention

• Prevention in the the 2025/26 Scottish Budget

• Audit Scotland reporting on health prevention

• Public Health Scotland’s Care and Wellbeing Dashboard

Public Health Scotland’s typology of prevention

As we mentioned in the first edition of Prevention Watch, when referring to health, the terms prevention and early intervention are sometimes referred to interchangeably, which can lead to confusion over what is actually meant. Public Health Scotland (PHS) has done a lot of thinking on this and has a published typology of prevention. The proposed three levels of prevention are helpful in providing clarity.

Primary Prevention: Reducing the risk of health issues occurring (“improving the conditions in which we work, live and grow”)
Secondary Prevention: Early identification of people who may be at risk of health problems and early intervention and treatment e.g. screening, health visitor checks
Tertiary Prevention: Reducing the negative consequences of health issues after they have occurred e.g. rehabilitation, dietary advice.
Primary prevention refers to the socioeconomic determinants of health inequalities and occurs largely outwith the scope of health services (i.e. the NHS). PHS put these different types of prevention on a scale of impact on population health being highest at the level of primary prevention, and lowest at the level of tertiary prevention.

Prevention in the the 2025/26 Scottish Budget

The 2025/26 draft Scottish budget was published on the 4th of December and, following Scottish Labour’s decision to abstain on the vote, will pass without amendments. The budget is split by portfolios which relate to areas of responsibility held by Cabinet Ministers. The Health & Social Care portfolio has ambitious aims: “it seeks to improve the health and wellbeing of our population, by preventing ill health, tackling health inequalities, and promoting healthier lifestyles.”

The delivery route for this set out in the budget, however, is almost entirely through secondary and tertiary prevention via health and care services. As stated in the Equality and Fairer Scotland Budget Statement: “The key to our ambition for our health and social care services and tackling health inequalities is ensuring that people have access to high-quality services when they need them.”

To find spend related to primary prevention, we need to look at other portfolios, for example, the social justice portfolio (covering housing & homelessness and social security), education & skills, economy (covering employment and regeneration), and transport. We saw some increases in spend in some key areas related to primary prevention. The affordable housing programme funding increased to very nearly offset the recent cuts to the programme. The commitment to mitigate the two-child limit from 2026 onwards could mean in the region of 20,000 fewer children in poverty although some significant uncertainties remain around when and how it will be delivered.

SSpend on housing and social security has clear potential to positively impact health inequalities but this isn’t always well articulated in the rationale and assessment of impact. For example, with reference to the spend on housing and homelessness, health outcomes are missing from that narrative describing the impact of its spend: “This [spend] is integral in tackling poverty and regenerating communities, as well as supporting economic growth and contributing to net zero targets”. Health outcomes do make it onto a bullet point list of secondary national outcomes related to the spend, but to be effective in tackling health inequalities, policy needs to be deliberate rather than incidental.

Conversely, tackling health inequalities is an explicit aim of the health and care portfolio where they have little attributable spend related to primary prevention which, as PHS point out, is where policy can have the most impact on population health. The Scottish Government will contend that there is cross-government working to tackle health inequalities, but there needs to be more consistent evidence of this joining up of priorities across budget portfolios.

Audit Scotland reporting on health prevention

Since October, Audit Scotland have released three papers examining Scotland’s public services and how they relate to prevention:

• Public service reform in Scotland: how do we turn rhetoric into reality?, released in November
• Alcohol and drug services, released in October, and
• NHS in Scotland in 2024: Finance and performance, released in December

Public Service Reform in Scotland: how do we turn rhetoric into reality? was written in conjunction with the Royal Society of Edinburgh and was based on roundtable discussions featuring small groups of experts from the Royal Society of Edinburgh, Audit Scotland, public sector leaders, and a variety of academic and policy experts. The discussion focused on what needs to be done to make necessary changes in the delivery and quality of public services in Scotland. Contributors considered why, despite long-standing policy commitments and evidence of benefits outweighing costs, it has been so hard to make the shift to preventative approaches within Scotland’s public sector. In particular, participants in the roundtable discussions “… felt that much prevention-based activity, although worthwhile, is tertiary or secondary… with too little emphasis on primary interventions.”

The report calls for a clear, overarching plan or set of measures to “… help Scotland track progress on its prevention journey.” Participants also noted that “organisational and accountability spaghetti” and sectoral competitiveness created a sense that Scotland’s current public sector arrangements often work against person-centred service redesign. The report calls for “effective accounting for preventative spend” in budget setting and financial reporting processes, as well as greater efforts to share positive examples of preventative action.

Audit Scotland’s report on Alcohol and Drug Services picked up on many of these themes, noting that there is limited funding or work being done at (primary) preventative stages for drug and alcohol harm: most funding is instead directed to NHS specialist services which treat people who are already in crisis stages. The funding that does go to preventative services is not tracked especially well.

Audit Scotland points out that there is data missing on demand, unmet need, and cost-effectiveness, which limits the ability to determine where funding for preventative interventions should be prioritised. There is also limited information about spending on community based support models, echoing the findings from the Public Service Reform in Scotland work, and limited evaluation of alcohol and drug service effectiveness.

In his comments on the launch of this report, Stephen Boyle, Scotland’s Auditor General, highlighted the need for preventative approaches, saying that “the Scottish Government needs to develop more preventative approaches to tackling Scotland’s harmful relationship with alcohol and drugs. This means helping people before they get to a crisis point.”

Finally, NHS in Scotland 2024: Finance and Performance reported that the Scottish NHS is struggling to meet growing population pressures or recover from COVID backlogs. The main message from the report is that the current healthcare delivery model is not sustainable and that “without an increased and ongoing focus on prevention, it is likely that any increases in activity or short-term service reforms will remain insufficient”.

The upcoming Scottish Government and COSLA’s Population Health Framework, which is intended to focus on primary prevention is cautiously welcomed: “it remains to be seen what takes priority, how actions will be delivered and monitored, and whether the cross-government and cross-sector buy-in required, can be achieved”.

Public Health Scotland’s Care and Wellbeing Dashboard

Working in partnership with the Scottish Government, Public Health Scotland has gone live with its care and wellbeing dashboard covering a variety of indicators featuring health, wellbeing, and socioeconomic inequality. This dashboard has been integrated with the ScotPHO profiles tool and aligns with the 8 Marmot Principles defined in a 2022 report from Michael Marmot and the Institute of Health Equity.

1. Good Early Years
2. Good Education
3. Good Work
4. Good Income
5. Healthy Places
6. Ill Health Prevention
7. Tackling Discrimination and Racism
8. Sustainability and Equity

Throughout 2024, Scottish Government analysts conducted consultations to identify potential indicators for inclusion in the dashboard. These indicators will be subject to ongoing review, with additional indicators and enhanced data breakdowns incorporated as new data becomes available and development efforts progress.

There are currently no indicators aligned to the final domain, Sustainability and Equity, although the dashboard is still in development and additional indicators are likely to come. The Scottish Government and PHS are open about the fact that it will need further work, and even in its final form is unlikely to meet the needs of all users. For example, it will not provide insight on which indicators are the most important to focus on. However, it’s good to see the breadth of indicators relevant to primary prevention, as well as the usual health outcomes, and we welcome the approach of the analysts involved to seek ideas for continuous improvement.