Prevention Watch – March 2025

In this edition we cover:

• A podcast from the University of Glasgow on ‘why prevention is so hard’

• An interview with Ivan McKee on prevention and public sector reform

• A deeper dive into homelessness prevention, featuring a toolkit for policy making from the OECD and early insights into findings from Upstream Scotland, a model for youth homelessness prevention

• 2 reports on the role of housing in recovery from addiction

• Prevention across the UK

University of Glasgow Spotlight podcast on ‘why is prevention so hard?’

A recent podcast from the University of Glasgow, presented by Prof. Graeme Roy, an economics professor and chair of the Scottish Fiscal Commission, and Prof. Nicola McEwan, the Director for the Centre for Public Policy, discusses the challenges and barriers to primary prevention. Their conversation covers some of the difficulties with implementing preventative programmes despite the consensus on it being the right approach.  The guests featured on the podcast were Caroline Gardner, the former Auditor General for Scotland, and Fiona Duncan, the strategic advisor for The Promise Scotland.

One of the key challenges to implementing preventative policy is that it requires money to potentially be shifted from things that will have an impact in the short-term to ones that will have an impact in the long term. Adding to this challenge is the short-term nature of our political system, where politicians are held to short-term outcomes and therefore may be incentivised to prioritise short-term solutions. There also may not be an obvious way to develop a long-term programme, and systems that are currently in place may be risk averse or resistant to change.

The panellists noted that one of the possible reasons Scotland struggles with making long term strategic policy decisions may be due to lack of a central Cabinet Office-type function in Scottish Government. There are pros and cons to having centralised cross-government coordination functions like the UKG Cabinet Office or Treasury, including concerns that it would become too powerful in certain contexts. These functions can play a central role in developing and following through on strategy, however.

Another point in the discussion was on the value of data and measurement. The panellists felt that Scotland does not measure things in a way that would help understand preventative policies. They noted that there is little information on community services, for instance, even though these services can be pivotal for primary prevention.

Interview with Ivan McKee on prevention and public sector reform

BBC Radio Scotland’s Good Morning Scotland discussed public sector reform with Ivan McKee, the Minister for Public Finance. This conversation was on the same day as a summit on public sector reform, held on 17th February, between Scottish Government, councils, businesses, and third sector organisations.

The interview addressed the Christie Report, which calls on shifting resources towards primary prevention. The Christie Report was published in 2011, and the presenter brought up frustrations people feel about the lack of what has been accomplished in the 14 years since. In a reply to a question on specifics for radical reforms for building on the Christie recommendations the Minister gave examples of areas that are being worked on at the moment, including shared services models wherein councils and health boards work more closely to better-align services and resources, and family support services in Glasgow and Dundee to join up services that  at are often siloed and can be difficult to navigate.

Whilst no doubt important examples of public service reform they perhaps fall short of what most people would think of as ‘radical’, and although the Minister talked about the importance of prevention, these are not solutions that necessarily resources upstream. At the time of writing, there was no published readout from the summit, but we’re sure we’re not alone in wanting to know a bit more about what was discussed, and potentially agreed.

The OECD toolkit to combat homelessness and early findings from Upstream Scotland, a pilot programme for youth homelessness prevention

In December, the OECD released a report which outlines good practice in designing policy for homelessness prevention.

Housing is a key determinant of health, and homelessness is associated with significant health risks. The OECD highlights that people who experience homelessness have an increased risk of ill health, including mental health conditions and substance use disorders. In Scotland, people experiencing homelessness are much more likely to die young, with over half of all homeless deaths occurring in people under 45.

The OECD Toolkit to Combat Homelessness emphasises the need to shift the policy focus towards prevention to better address homelessness, and importantly, highlights strategies for preventing  homelessness.

Strategies include ensuring access to affordable and social housing, ensuring that tenants and property owners have balanced rights and protections, and providing targeted support for individuals being discharged from institutions such as prisons, hospitals, and care facilities.

Scotland was mentioned a few times in the report, and Scotland’s Affordable Housing Supply Programme was highlighted as a positive example of preventative spending (although we would note that at the moment, the homelessness rates continue to grow despite this investment).

Another challenge associated with preventing homelessness is that it can be difficult to understand who might be at risk. One homelessness prevention scheme they highlighted was Upstream Cymru, which assesses students in Wales for their risk of homelessness through a survey. Students at risk of homelessness are then offered support, often in the form of emotional support or help navigating local services.

A Scottish version of this programme, Upstream Scotland, was launched in 2023 in six secondary schools across Edinburgh, West Lothian, and Perth and Kinross and a report discussing findings from the first year of this programme came out in February. A key finding was that around one in ten students in these six schools were at risk of homelessness, and that schools may not be aware of these students at risk. It is too soon for the programme to know if it will have an impact on homelessness, but they found that about half of the students that were identified and offered support accepted it.  Another key finding was perhaps unsurprising: students at risk of homelessness reported much lower levels of wellbeing with student who ended up being assisted by the programme then reporting higher levels of wellbeing.

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Two reports citing the importance of housing in preventing drug deaths

Healthcare Improvement Scotland published a short article in February on the value of secure housing in supporting people in addiction, treatment, or recovery.

The article is part of a programme aimed at reducing drug-related harms and making drug treatment services more accessible and discusses how important housing is in supporting people in recovery. They make a key point that short-term accommodation can worsen addiction and trauma, rather than providing people with the stability that is needed in recovery.

Whilst this fits more with the definition of ‘tertiary prevention’ (i.e., an issue getting worse rather than primary prevention which stops it happening in the first place) we are including it here because it shows the importance of socioeconomic interventions working in tandem with health interventions.  The article calls for housing and health service integration when working with people who have complex health issues associated with homelessness, such as addiction and mental health conditions.

Scotland has the highest mortality rate from drug misuse in Europe, with nearly 1,200 deaths from drug misuse registered in 2023 but it does not publish data on the urban-rural divide when it comes to these deaths.

An article from the BBC, published in February, highlights oversights in rural drug deaths, discussing Oban, where at least eight people have recently passed from suspected or confirmed drug misuse. The article discusses some key issues surrounding addiction in rural communities, highlighting issues accessing support for people struggling with addiction and mental health conditions.

The article also highlights housing services in rural local authorities, discussing how support may not be available near a person’s home community. The article talks about a young man, upon release from prison, being offered housing from Argyll & Bute Council in Dunoon and Helensburgh, several hours away from his family and support system in Oban.

Scotland’s housing strategy document, Housing to 2040, also discusses the problems with housing and makes reference to work it is doing with Healthcare Improvement Scotland on healthcare and housing. The strategy also acknowledges issues rural communities face, which is expanded upon in the Rural & Islands Housing Action Plan. The Scottish Government has pledged to provide 110,000 affordable homes by 2032, 10% of which are to be in rural and island communities. This is clearly part of the solution, but ensuring they are in the right place is an additional challenge.

Prevention across the UK

Back in January, the chief secretary, Darren Jones, delivered a keynote speech at the Institute for Government annual conference in which he discussed ways of understanding prevention. The government is currently piloting a new model which would forecast the preventative benefit of new policies, which would ideally allow us to better understand how programmes could influence health in the long run and allow the UK government to make better spending decisions. The Institute for Government notes that this could also be used to develop better definitions of preventative spending, and ringfence that funding in the future.

Methods of valuing prevention and forecasting health are not new, but finding the right model and the right data will likely take a long time. Nevertheless, this is an interesting development, and we look forward to seeing how they choose to calculate these benefits in the future.

A report from Demos and the Health Foundation, released in February, discusses moving towards preventative spending models and also makes the case for ringfencing funding for prevention. The report lays out four key recommendations for the UK Government in order to shift public spending towards health prevention:

1.       Creating a working group to develop a definition of preventative expenditure

2.       Create a create a Preventative Investment Unit to apply this definition across departmental budgets and support implementing preventative departmental expenditure limits into budgets and spending reviews

3.       Passing an act to create a target for preventative spending

4.       Develop a Preventative Investment Challenge to fund the development of a variety of preventative programmes

For this to be successful, the UK Government would need to make a cultural change, looking at long-term outcomes rather than short-term solutions, echoing the discussion from the University of Glasgow podcast discussed earlier.

Finally, the Chartered Institute of Public Finance and Accountancy (CIPFA) conducted a webinar on prioritising prevention, bringing in speakers on public finances and prevention from across the UK.

Speakers included Jo Bibby, from the Health Foundation, discussing the building blocks of health; Paul Johnston, from Public Health Scotland; Jim McManus, from Public Health Wales; Mike Burns, from Glasgow City Health and Social Care Partnership; Vicky Davis, from the National Audit Office; and Zach Scott from CIPFA.

Their talks highlighted why prevention works, barriers to taking preventative approaches, and the various steps each department within the UK Government is taking to prevent ill health, repeating themes discussed throughout this briefing.