Prevention Watch October 2024

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. By prevention, we are referring to public policy interventions that prevent poor outcomes in the future, as opposed to policy which intervenes to mitigate harms once they have already occurred or subsequently deals with the consequences.

You can read a PDF version of this report here. 

At SHERU our focus is on the socioeconomic determinants of health inequalities. In other words we’re concerned with preventing poor health outcomes by tackling causes that sit outwith the traditional realm of health policy the healthcare system. To take one example, damp and mould in a home can cause respiratory disorders. Rather than the NHS treating the illness, a preventative approach would fix the damp and mould.

The arguments set out in the Christie Commission in 2011 are the same arguments being made by health leaders in 2024. For example, reflecting on Scotland’s ageing population, the Chief Executive of Public Health Scotland, Paul Johnston, has recently argued that “we have no option really other than to work very hard to increase our prevention focus…because the reality is that we cannot afford continue to deal with the entirely preventable harm that the NHS faces day in day out”. [ii]

This briefing is created to shine a light on interesting prevention related developments. This might be new policy evaluations, blogs, or policy announcements… or whatever catches our eye.

In this edition we cover:

  1. Comments from the Auditor General on the importance of leadership in prevention
  2. Parliamentary scrutiny of the resource implications of prevention in relation to homelessness and suicide legislation
  3. The Chief Executive of Public Health Scotland on the poverty dimension of health outcomes
  4. The Scottish Government’s ‘vision for health and social care in Scotland’ and being clear what we mean by prevention

As this is the first brief we start with a recap on the Christie Commission and its recommendations on prevention.

The Christie Commission and Prevention: Recap

The main recommendations relating to prevention were in Chapter 6, titled ‘Prioritising prevention, reducing inequalities and promoting equality’.

The report advocated for a substantial shift from dealing with the consequences of social problems to preventing them from arising in the first place. It argued that as well as leading to better long-term outcomes, a more preventative agenda should also reduce the overall cost of public services through avoiding more severe problems and higher costs later on.

In 2011, when the Christie Commission was putting forward its recommendations, Scotland had few options for raising revenue from devolved taxation powers, and the report therefore focused on options for shifting resources available to the Scottish Government (from UKG through the Barnett Formula). In 2024, there are now more devolved powers available to the Scottish Government, including on taxation, which opens up new options for delivering prevention action. The Commission was working during a time of declining budgets and recognised that reallocating monies was no easy matter. However, the report stated that there is:

“no alternative: if we do not manage to effect a shift to preventative action, increasing ‘failure demand’ will swamp our public services’ capacity to achieve outcomes. In all aspects of our system of public services, therefore, from setting national policy to reforming the governance and organisation of public services, through to the design and delivery of integrated services, all parties must prioritise and build in action which has the effect of reducing demand for services in the longer run.”

To ensure the effectiveness of preventative measures, the Commission highlighted the importance of monitoring and evaluating initiatives, tracking outcomes, and using data to refine and improve preventative strategies over time.

1. Comments from the Auditor General on the importance of leadership in prevention

Stephen Boyle, Scotland’s Auditor General, released a blog in August to mark 4 years in the job and talked about how the Scottish Government needs take on a greater leadership role to ensure urgently needed reforms lead to a shift to a more preventative approach. [iii]

Noting the tight fiscal environment, he acknowledged the inevitability of spending reductions in some areas to allow for investment in others, but argues that needs to be done “in a planned way, with good governance and effective leadership at its heart”.

Prevention, or the lack of it, has been a key theme of much of the Auditor General’s comments during his time in office. His blog from a few years ago on the 10th anniversary of the Christie Commission is worth a read. [iv] In that he reflects that audit work consistently shows a gap between policy ambitions and what is delivered on the ground (what we at SHERU term the ‘implementation gap’.

2. Parliamentary scrutiny of the resource implications of prevention in relation to homelessness and suicide legislation

New statistics, covered in our latest Reactive Stats briefing, showed that, in 2023-24, households assessed as homeless have reached their highest level since 2011-12. [v] The reasons why people become homeless are many and varied and preventing where possible people from having to leave their home is hoped to be one way of stalling the continued deterioration of homelessness figures.

The Housing (Scotland) Bill, currently at Stage 1 in the Scottish Parliament, includes a ‘shared public responsibility to prevent homelessness’ where public bodies and housing associations who come into contact with people who they suspect may be in a precarious housing situation will have a duty to proactively take steps to mitigate this risk (referred to in the legislation as the ‘Ask and Act’ duty, but also referred to by stakeholders as the ‘duty to inquire’). [vi]

Putting it in legislation does not guarantee it can or will be enacted in practice. There are, of course, resource implications. The Scottish Parliament’s Finance and Public Administration Committee has cited evidence received from stakeholders that raise significant concerns around the provisions set out in the Financial Memorandum (FM) accompanying the Bill. [vii]

“…evidence received by this Committee raised significant concerns that the staffing costs set out in the FM would not be sufficient to meet the resourcing required for additional demand and that the FM does not recognise the potential for increased workload not only for homelessness services, but also for other agencies which will receive referrals, such as Community Advice Services and Tenancy Support. The City of Edinburgh Council , for example, estimates that, “if there was a 25% increase in presentations, an additional 42 employees would be required, at a cost of £1.9 m per year for internal staffing”. This is compared to the figure stated in the FM, of £1.6 m per year for all 32 authorities.”

At the Scottish National Party conference in August 2024, the Scottish Government Housing Minister indicated that the homelessness prevention duties will not be introduced as soon as the Housing Bill becomes law and said he will instead “be guided by the sector in terms of when is the best time to bring this in”[viii]. How this translates through to amendments in the legislation will become clearer as the Bill goes its stages of debate and scrutiny in the months ahead.

This ‘double funding’ predicament (as noted in the Christie commission report) can be a substantial barrier to implementing preventative approaches. Prevention of homelessness should mean that less money needs to be spent later on homelessness services. But until that feeds through, there will be calls for money to be spent simultaneously on both prevention and dealing with the existing caseload.

Another area where the Scottish Government have signalled a shift to prevention but have faced a similar resourcing predicament is on the ‘Creating Hope Together’ suicide prevention strategy. [ix]

Earlier in the summer, the Equalities, Human Rights and Civil Justice Committee published the findings from evidence they had heard.[x] Support for the strategy, along with concerns over whether resources are available to support the shift to a more preventative approach were front and centre:

“The Committee heard broad support for the Creating Hope Together Strategy and welcomes its shift in focus from viewing suicide as a mental health concern to one of a public health challenge with a focus on inequalities as a driver. We note that it is too early to meaningfully evaluate its impact, but that it is clear that tackling inequalities will require resource, cross government and a cross community approach. It is not yet evident that sufficient resources and cross government working is in place, and we look forward to monitoring progress in those areas alongside the strategy as it is implemented.”

A whole government approach is set out in the strategy, involving a range of services working together to ensure early intervention, rather than acting at the point people are suicidal. These services/organisations are also in scope for the “Ask and Act” duty. There is also clear overlap in the target group: a quarter of people who have not been able to ‘maintain accommodation’ cite mental health as the main reason. [xi]

Decisions on funding, and on monitoring and evaluating impact, can and should recognise the commonality in determinants where they relate to socioeconomic inequalities – which extend to many other outcomes, including poverty, educational outcomes and productivity. It could make funding prioritisation more straightforward where there is evidence of impact across multiple outcomes from funding the same services and lead to efficiencies in spend – rather than two different funding streams coming to services with slightly different frameworks for reporting and measuring impact.

3. The Chief Executive of Public Health Scotland on the poverty dimension of health outcomes

As already mentioned in an earlier section, the Chief Executive of Public Health Scotland, Paul Johnston, has been speaking about the criticality of tackling poverty as a way of preventing health inequalities in the future.[xii] Whilst he noted elements of Scottish policy in relation to public health interventions have been bold, he highlighted that Scotland continues to grapple with the social and economic issues that are major contributors to ill health.

In response to a question about how prevention can survive budget pressures, he noted that not all preventative policies have to be expensive (although acknowledging that many are). Examples included public health policy that incentivises and disincentivises behaviour around things like alcohol and diet (e.g., through licensing of which premises operate where and legislating on offers available in shops for unhealthy options), as well as encouraging employers to provide good jobs.

It’s good to hear some optimism about what can be achieved, even in this tight fiscal environment. Although we note that the legal challenges, and the high associated costs, we’ve seen in response to some of Scotland’s public health measures in the past will weigh on the minds of the government when thinking about similar new initiatives.

4. The Scottish Government’s ‘vision for health and social care in Scotland’ and being clear what we mean by prevention

In June 2024, the Cabinet Secretary for Health and Social Care outlined the Scottish Government’s ‘vision for the health and social care system’. Prevention is mentioned multiple times. In a look over the Cabinet Secretary’s statement to the Scottish Parliament and the transcript of the subsequent debate, there are two interpretations related to ‘prevention’ – 1) prevention related to socio-economic determinants of health and 2) prevention related to early (healthcare) interventions.[xiii] The Cabinet Secretary in his speech, explicitly mentions prevention and early intervention together in the same sentence. Some members talked about one or both, and it often seemed that the two were being conflated.

Whilst they are no doubt complementary, they mean different things in practice. For example, early healthcare intervention keeps the expenditure in the health portfolio but prevention in relation to socio-economic determinants of health, sits outside the health budget. Whilst both have a role in public service delivery to reduce health inequalities, conflating them adds to confusion over what is being done in the name of prevention, and why.

There is an interesting broader question as to what people actually mean when they talk about prevention. There is a possibility that ‘prevention’ is a ‘chameleonic’ term that is attractive not only because it sounds good but also because it can be strategically adapted to suit the interests of wide-ranging audiences with different interests (e.g., it can be used to mean both prevention and early intervention, depending on who policymakers are talking to).[xiv] Chameleonic ideas are politically useful since they help achieve cross-sectoral buy-in, but they can also be hard to put into practice in ways that deliver meaningful change due a lack of clarity of approach.

Thanks for reading this edition of Prevention Watch.

At SHERU, we’ll be working to identify and scrutinise some of the difficult policy choices that are required if Scotland is going to realise its commitment to prioritising prevention. We’re particularly interested in policy decisions impacting on key socio-economic determinants of health inequalities (e.g., housing, employment and income). Going forward, Prevention Watch will be shining a light on some of the difficult choices involved in achieving a preventative policy shift, while the broader work in SHERU will consider the evidence supporting distinct policy options.

If you want to suggest issues for us to keep an eye on, or just be kept up to date with what we are saying and doing, you can sign up to our mailing list by emailing sheru@strath.ac.uk.

Sources

[i] Commission on the Future Delivery of Public Services (2011), available here

[Ii] Reform Scotland webinar (2024) ‘Paul Johnston ,Chief Executive of Public Health Scotland, in conversation with Chris Deerin’. Available here. Comments made at 20:33.

[IIi] Boyle, S, Auditor General for Scotland (2024) ‘Shrewd approach need for public sector success’, available here

[iv] Boyle, S, Auditor General for Scotland (2021) ‘Christie’s clarion call can’t wait another decade’, available here

[v] Jack, D & Smith, K.E. (2024) ‘Reactive Stats Summary: Homelessness in Scotland Statistics 2023-24’, Scottish Health Equity Research Unit (SHERU), available here

[vi] Housing (Scotland) Bill pages on the Scottish Parliament website, available here (accessed on 2nd October 2024)

[vii] Letter from the Convenor of the Scottish Parliament Finance and Public Administration Committee to the Convenor of the Local Government, Housing and Planning Committee dated 7th October 2024, available here

[viii] Riding, J (2024) ‘Homelessness prevention duties will be phased in, Scottish housing minister says’, Inside Housing 30th August, available here

[ix] Scottish Government (2024) Creating Hope Together – Year 2 Delivery plan (2024-26), available here (accessed on 2nd October 2024)

[x] Scottish Parliament Equalities, Human Rights and Civil Justice Committee (2024) ‘Suicide Prevention in Scotland: Findings and recommendations’, sent as part of correspondence with the Minister for Social Care, Mental Wellbeing and Sport dated 28th June, available here

[xi] Scottish Government (2024) Homelessness in Scotland 2023-24. Reasons for Homelessness and Prior Circumstances webpage, available here (accessed on 9th October 2024)

[xii] See ii and also Johnston, P (2024) ‘A Scotland where everyone thrives’, speech to The State of the Nation event on Tuesday 17th September, as printed on the Public Health Scotland website, available here

[xiii] Official Report of the Meeting of the Parliament Tuesday, June 4th, 2024 ‘Debate on motion S6M-13466, in the name of Neil Gray, on a vision for health and social care in Scotland, available here

[xiv] Smith, K.E. (2013) Beyond Evidence-based Policy in Public Health: The Interplay of Ideas. Basingstoke: Palgrave Macmillan.