Professor Paul Cairney, University of Stirling

Professor John Boswell, University of Southampton

Dr Emily St Denny, University of Copenhagen

Paul Cairney, John Boswell, and Emily St. Denny explore the resurgence of the idea that ‘prevention is better than cure’ in UK Government rhetoric. If this idea has risen then fallen off the policy agenda so often, what would make the difference next time? One new set of ideas comes from a co-authored report with the NHS Confederation on ‘unlocking’ prevention.

The UK Labour government has revitalised the well-established idea that ‘prevention is better than cure’. Prime Minister Starmer is leading a push to boost healthy behaviour in the population, and NHS reform, to reduce health inequalities and pressure on public services.  This idea is part of a wider attempt to address severe financial constraints while improving public services.

The main problem is that we have been here before. Our work identifies a long history of UK postwar prevention policy characterised by bursts of enthusiasm with limited effects.

Successive governments recognise that prevention may be the most important policy agenda of their time. They have proposed to reform policy and policymaking fundamentally, such as to shift public service resources from reacting to acute problems to the prevention of problems before they occur.  They have signalled the chance to reduce inequalities and public spending while joining-up government.

However, we found that post-war UK governments have not known how to  ‘institutionalise’ this prevention agenda. We identify cycles of enthusiasm and bursts of initiatives, followed by disenchantment with slow progress and reduced activity when governments move on to other agendas. This problem is not specific to health or policy in the UK. We find the same disenchantment across the globe.

Three factors explain this profound gap between enthusiastic intent and real-world practices: low clarity, congruence, and capacity.

Clarity: if prevention means everything, maybe it means nothing

The language of prevention is vague, which helps to maximise initial support but delays discussion on how to translate abstract aims into concrete action. Eventually, intense debates take place about the priority, such as reducing inequalities or costs, and policy tools, from providing individuals with information, to regulating behaviour, reorganising services, or taxing/spending to redistribute income. In other words, some want to intervene and redistribute resources and others want individuals to take responsibility for their own wellbeing. The range of possible activity is also vast, from whole population efforts (primary prevention), identifying at-risk groups (secondary), and preventing known problems from getting worse (tertiary).

Congruity: prevention is out of step with routine government business

When governments make sense of prevention, they struggle to relate it to the everyday routines and rhythms of policymaking or connect it to higher priority agendas. For national governments, it does not deliver economic growth or ‘cashable’ savings, service reorganisation is not a quick fix, and the prospect of taxing and spending to redistribute resources or new ‘nanny state’ laws to regulate behaviour is not appealing. The offer of long-term improvements does not help a government declare immediate success. For local public bodies, prevention is a great way to collaborate but only after they deliver their higher priority commitments.

Capacity: low support for major investments with uncertain rewards

Preventive policies are often akin to capital investment – spend now and benefit in the future – but without a clearly supported way to demonstrate a return to investment. This offer is not attractive to governments seeking to avoid controversy and reduce spending. Rather, prevention may represent a political ‘leap of faith’ or investment of ‘political will’ that few policymakers are willing to take, and require a level of ‘systemic capacity’ that is difficult to find.

What could make the difference?

Cairney and Boswell worked with the NHS Confederation to examine how to boost the clarity, congruence, and capacity of preventive policies in integrated care systems (ICSs) across England. These ICSs provide a means for health bodies and local governments to produce a joint strategy for their area, and to put ‘prevention’ at its heart.

In focus groups with ICS leaders and partners, we found:

• high commitment to the broad idea for prevention, but reflection that it was often used loosely and ambiguously in practice to mean all manner of things;
• high barriers to aligning long-term preventive health policies with immediate firefighting in public services
• promising strategies not backed by systemic capacity.

If so, what experiences of prevention can help to overcome routine barriers to change? Participants described a wide range of useful initiatives in innovative ICSs, to boost leadership and collaboration, connect preventive aims to core business, and harness key facilitators – such as data and decision-making infrastructures – to make tangible progress.

In that context, the new NHS Confederation report makes the case for additional national and ICS measures to promote this kind of progress across the whole ICS landscape. From the UK government, the Confederation seeks: ‘a national framework for measuring prevention spending’ to allow UK governments and ICS partners to measure clearly defined progress, create powerful ‘financial and regulatory incentives’ to help make prevention congruent with new routines in government business; and, meaningful autonomy to build systemic capacity in areas such as ‘the data, digital and technology workforce’ and ‘promote a culture of learning and best practice’. In other words, while ICSs may be ultimately responsible for defining and delivering preventive policies, they need the financial, legal, and political support from UK ministers to succeed.

• Read the report: https://www.nhsconfed.org/publications/report-unlocking-prevention-integrated-care-systems

• Access the guide: https://www.nhsconfed.org/publications/guide-unlocking-prevention-ICSs