Our prevention crisis
‘Crisis’ was a medical term used primarily in a health context for centuries. It referred to the decisive point of an illness or injury that determined whether recovery would happen.
In more modern times, ‘crisis’ is the ubiquitous metaphor for any situation in which an urgent and important problem needs resolution.
In government, ‘crisis response’ is usually seen as the opposite end of the policy spectrum from ‘primary prevention’. The difference is one of timing. The first deals with a crisis after it has happened; the second takes effect before it occurs.
Scotland's Chief Medical Officer on what is better than a cure
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Manifestos must address prevention
Both primary prevention and robust intervention are essential. There is no plausible ‘either/or’ position.
The Christie Commission on Public Service Reform called for a rebalancing of these two elements. Approximately 40 per cent of all public spending went to ‘clean up messes that could have been prevented’ at a lower financial and human cost.
Increasing ‘prevention’ and decreasing ‘failure demand’ have been embraced in principle as fully as could be hoped. The Scottish Parliament’s Finance Committee continues to pursue this with cross-party support, while the Scottish Government has officially declared ‘preventative spending’ as a priority.
Consequently, favouring the principle of ‘prevention’ should not distinguish political parties in the 2016 Scottish election. This is a debate for every level of government and community across Scotland. Nevertheless, they should compete in the forthcoming campaign in answering three questions:
- What will each party commit to prevention?
- How will prevention be made meaningful and effective?
- Where will evidence on prevention come from and what will ‘count’?
To cite just two examples, what commitments will be made on prevention ‘impact assessments’ and on budgetary incentives for successful preventative spending?
Keeping harm from happening in the first place should be a focal point for the energy, commitment to social justice and desire for public engagement under any constitutional arrangement unleashed during the 2014 independence referendum and the recent election. It is a goal to which nearly everyone can contribute in different ways.
Why health policy and practice exemplify Scotland’s ‘prevention’ crisis
Going back to the original meaning of ‘krisis’, Scotland has reached that decisive point when primary prevention will either become what we succeed at doing or become trivialised and diminished into an aspirational slogan we are only good at applauding. Shifting the balance significantly in favour of primary prevention through public policy, governmental resource allocation and institutional behaviour cannot long remain in the limbo of being officially embraced and practically sidelined. Doing so only invites unwelcome cynicism and unhealthy alienation.
Elsewhere, we have argued that the UK’s austerity policies and spending cuts help explain why Christie’s startling figure of 40 per cent of Scotland’s public spending on failure demand has probably gone even higher in the ensuing five years. Austerity impacts most on the least well off. This has the perverse consequence of increasing the demand on numerous public services on which the least well off must rely.
By creating additional cases of immediate misery piled on top of existing unmet service needs, austerity has created a new form of ‘failure demand’. This is the backdrop for the UK as a whole and a trend against which Scotland continues to struggle in order to transform its public services. But austerity cannot be allowed to become an excuse for inaction in making the transformative shift to primary prevention.
Health is, of course, not the only arena in which this contradiction between rhetoric and reality exists but illustrative of ways of thinking and acting that are counterproductive in getting the balance right between primary prevention and crisis response. There are several questions that should spark debate.
First, why hasn’t Scotland more fully embraced (in practice) the wisdom of giving priority to creating health, alongside combatting illness and treating symptoms?
Although he is rightly celebrated, the main message throughout Professor Sir Harry Burns’ recent tenure as Scotland’s Chief Medical Officer was that ‘salutogenesis’ – helping people of all ages and stages create the greatest possible health – was not acted upon fully.
This approach is emphatic that creating health is not only the best sort of prevention, but also the most cost effective, economically productive and society enhancing role for public bodies to embrace. This must include those outwith the health arena - from education and housing to agriculture and economic development. What all these sectors do (or fail to do) impacts upon our collective ability to have a healthy Scotland, as well as a nation in which pernicious health inequalities are dramatically reduced (if not eliminated).
Second, why are so many of the current NHS HEAT targets and standards still so reactive, ‘downstream’ and numbers-driven, e.g. ‘Psychological therapies waiting times’ and ‘Alcohol brief interventions’?
These are worthwhile goals and areas for improvement. Life is bleak for a depressed teenager who must wait months before help even begins to arrive. But, what is conspicuously missing is adequate and equitable attention to what public services could, and should, have been doing much earlier in people’s lives to make such therapies and interventions unnecessary.
Primary prevention is about doing whatever is possible to help people become and stay healthy, positively engaged and successful enough to keep from ever falling over the edge or being driven to drugs, drink, crime, violence and other social ills. What is needed is an effective ‘both/and’ strategy that cuts across the entire public sector. It has become the conventional wisdom to decry the presence of agency/professional silos and to advance the idea of integrated/joined-up public services/supports. But, it is still not the reality of how budgets are developed, resources are deployed and results are measured.
Third, why has public health become so disconnected from the public?
Improving public health and eliminating health inequalities requires structural changes – especially poverty reduction. However, it also depends upon consistent, positive, two-way relationships of trust between professionals/practitioners and the people with whom they work (and who are the intended beneficiaries). There is evidence that some good public health advice and assistance initiatives have unintentionally exacerbated health inequalities because they did not operate within the context of respectful, compassionate relationships.
The people whose behaviours have been influenced most by previous public health efforts have often been the ones least in need of assistance. And yet, research indicates that many people previously (and erroneously) regarded as ‘hard to reach’ are much more likely to hear and heed the exact same information and advice when help is offered in the context of a positive, respectful, trusting relationship with the providers. Thus, the real need is for better, relationship-based support, rather than simply increasing the size of the workforce or technological substitutes for relationships.
While the full story is complex, the simple reality is that family history; peer/partner attitudes; commercial advertising/media influences; and, social norms have been (and remain) more powerful explanatory variables for many health behaviours than the work of public health. Therefore, the solutions to this type of ‘public health problem’ reside in what a wide range of people – predominantly those outwith the public health ‘silo’ – think, say and do. Specifically, it means working with these influential parties as equal partners (and not regarding them merely as ‘service users’, ‘clients’, ‘cases’ or through other disempowering labels).
Historically, many of public health’s greatest triumphs have come in areas where it really could exert control over the most crucial variables (e.g. technologies, vaccines, infrastructure and, occasionally, legislation). In these instances, public health agencies usually ‘did the right thing’ and to the huge benefit of Scotland’s people.
Now, however, the key to a healthy Scotland can be found in an ‘all hands on deck’ effort to: create health by developing and sustaining a host of healthy relationships within and across schools, agencies, families, professions, communities, and civic society. This, in turn, will finally enable Scotland to get the balance right between primary prevention and crisis response.
Scotland’s policymakers want a shift to prevention but are unable to affect it at pace. Acknowledging this situation is the first stage towards addressing the challenge.
Three responses worth consideration are:
Shifting mindsets in governmental training and workplaces
There remains a remarkable lack of emphasis on prevention in recruitment and socialisation. Consider the job descriptions and training in a range of public services. How often is prevention emphasised or even mentioned? How often are public officials promoted primarily for doing great preventative work?
Leadership plays an important part. If the message from the top is not explicitly and consistently in favour of prevention, then the behaviour is unlikely to change. There is a need to consider the extent to which the very idea of primary prevention is given the place it merits in public bodies.
Rearranging institutional priorities
If public services fail to permit space for prevention, then there will be no actual shift to prevention. From the outset of collaborations, inter-agency activities and joint projects, the mindset and priority of prevention needs to be emphasised by leaders and embedded by staff. Rather than focusing on meeting numerical delivery/input targets over, a decisive institutional shift to primary prevention will, over time, result in a range of human, financial and societal benefits
Realigning public service goals toward preventative objectives
This may seem obvious, but currently there is little effort to make it happen. Public bodies need to think again about the set of rewards and incentives for pursuing prevention that are used to encourage and reward public service workers (and the organisations with which they have a collaborative, commissioning or evaluative relationship).
The time has come to create manifestos that move beyond hitting targets, but missing the point. The role of government is to help build a social consensus and help support the numerous ways (many already proven successful at a modest scale) to enable, encourage and enhance Scotland’s people and communities. The 2016 Scottish election and its aftermath have the chance to be a positive ‘crisis’ - that decisive point in our collective history in which we powerfully turn toward healing and health. •
John Carnochan OBE QPM FFPH was Co-Founder of the Violence Reduction Unit and author of the book, ‘Conviction’. Edinburgh University’s Professor of Public Policy, James Mitchell, was a member of the Christie Commission. Dr Jonathan Sher has been the first coordinator of the Scottish coalition behind Social Justice Begins With Babies.