The Huddle: How do we make Scotland healthier?

With health an important election issue, Holyrood asked experts:  How important is a shift to spending on preventative health initiatives and can that be done without impacting existing health services? 

• Dr Cam Donaldson, health economist and Emeritus Yunus Chair, Glasgow Caledonian University

It is common and natural to ask this question. It is also naïve, playing into the hands of governments lacking the will to create the means to make prevention work. 

When evaluating a new pharmaceutical, national agencies, such as NICE, compare increments in health and wellbeing against its net cost. There is no presumption as to cost savings. Why should prevention be held to an unfair standard of financial payback and relieving pressure that we do not apply to those other interventions? 

Furthermore, if there is ‘payback’ to be had it would materialise as cash to be stripped out of the NHS to pay for other things. Rather, it takes the form of allowing the NHS to do more with the resources it has. This may translate into cash savings in the long run but not over the ridiculously short payback periods often set by government agencies.

Until governments create the fairer society required to improve the health of the worst-off and reduce health inequalities, the outlook for prevention and for health inequalities does not look good. To do this, we need to have a perspective that values prevention not as some money-saving device but as valuable in its own right. 

• Dr Calum Lindsay, research associate, Social and Public Health Sciences Unit, University of Glasgow 

Fifteen years after the Christie Commission heralded a move towards preventive policymaking, many of the problems it sought to address have worsened. In part, this is because preventive initiatives are often confused with early identification and intervention. Many of the fundamental causes of poor health and health inequalities exist ‘upstream’ from the health service and are beyond the power of the NHS to fix. Attempting to take preventive action without addressing these causes means those actions will almost always be undermined.

That said, some preventive changes should impact existing health services to ensure the NHS does not reproduce health inequalities through inequalities of access that cause people to become ‘missing’ in healthcare settings. More time should be spent working beyond the health service by material income inequalities, distributing health-protecting resources more equally, reducing exposure to the determinants of ill-health, and taking a truly preventive approach to good health.

• Professor Andrea Williamson, GP and professor of general practice and inclusion health, University of Glasgow 

Prevention is about using everything in our power to ensure people are healthy and thriving. Most of that sits outwith the health service and is about reducing wealth inequalities markedly and addressing the wider social determinants of health. Health in all policies needs enacted urgently and we need to be wiser at pushing back on the commercial determinants of (ill) health.

Within healthcare, a focus on primary healthcare we know is much more cost-effective, especially when it prioritises continuity of care for patients. Get this right (or even less wrong) and pressure will reduce. Moreover, applying a missingness lens to healthcare can tangibly reduce health inequalities, further boosting prevention of ill health in the future.

• Dr Chris Provan, chair of the Royal College of GPs

There is now broad agreement that more care must shift into the community and prevention should be prioritised. This approach is more cost-effective, protects specialist services, and delivers better outcomes for patients. 

It is disingenuous to pretend that achieving this shift is possible without a real rebalancing of resources. In the years ahead, more funding, staff and infrastructure will need to be directed into community settings.  

We have already seen this begin: the Scottish Government’s recent investment in general practice involved reallocating money from within the existing health budget, however this must mark the start of a shift and not the end point. General practice still receives a smaller share of the health budget than it did 10 years ago.

If we are serious about a preventive, sustainable health system, this pace of change must accelerate. Inspiration should be taken from Denmark, where bold, financed steps towards prevention have found cross-party agreement.  

• Sara Redmond, chief officer of development, Health and Social Care Alliance Scotland (the Alliance)

Imagine the scene. Scotland run out for their World Cup opener, but every player is a goalie.

The only way to win is to defend. That’s essentially how the NHS and social care provision operates. We react to crisis, instead of playing up the pitch to prevent goals. 

Shifting towards prevention is a moral imperative. We must prevent the causes and consequences of poor health and improve people’s health and wellbeing. People deserve a better system. Saving on inefficiencies would allow money to be spent more wisely. We need targeted investment and strong leadership, and to learn from the third sector how its prevention work stops own goals, for example, poor health caused by poverty. This is key to improving health and wellbeing in Scotland. 

We can’t continue to invest in goalkeepers. We must build a winning team of invested partners – many of whom already have solutions. We need to ask ourselves is defending truly better than winning?

• David Finch, assistant director, Healthy Lives Team at the Health Foundation

A preventative shift isn’t optional – it is fundamental. While clinical care matters, the biggest influences on our health are the social and economic conditions people live in, and inequalities in these are widening. The causes are deep-rooted and structural, made worse by successive crises – a sustained long-term preventative response is essential.

But progress in the short term is entirely possible and this shift doesn’t have to come at the expense of existing services. The challenge isn’t a lack of ambition or funding but a gap in implementation, with fragmented action holding back progress. Strengthening cross‑government working and aligning local and national efforts can create the capacity to invest in prevention without undermining frontline care. Ultimately, prevention is the most effective way to improve Scotland’s health, close inequalities and reduce pressures from acute need.

• Angela Mitchell, head of Nesta Scotland

Excess weight is linked to a wide range of serious health conditions which not only impacts people’s quality of life and health but has clear knock-on effects for the economy and businesses too. Far too little is invested in obesity prevention strategies, which typically take longer to bear fruit.

But effective prevention can save money. The UK Government’s healthy food standard, based in part on a policy proposal by Nesta, would see large food businesses mandated to improve the healthiness of the foods they sell. It represents one of the most ambitious and potentially impactful obesity policies announced anywhere in the world and could reduce obesity by around a fifth if adopted in Scotland.

Prevention will free up beds, reduce strain on GPs, and reduce the need for pharmaceutical interventions, ultimately contributing to a healthier Scotland so we can live more years in good health. 

• David Phillips, associate director, devolved and local government finance,  Institute of Fiscal Studies

A shift in activity and spend from hospitals and treatment into the community and prevention could, in principle, support better outcomes for Scots, and help address long-term fiscal pressures. 

In practice though, such a shift in approach is likely to require an up-front increase in spending – adding to budgetary pressures – before potential improvements and savings materialise. 

The current Scottish Government’s spending review envisages a huge shift in health spending in 2027–28 and 2028–29; after accounting for inflation, plans envisage little if any increase in funding for hospitals and the ambulance service, but nearly 12 per cent a year increases for support for primary and social care.

Ambitious? Certainly. But realistic? In my view, no – not least given the need to tackle still-elevated waiting times for hospital treatment, and upwards pressure on staff and drugs costs. 

A genuine shift in health spending and policy is a multi-parliament endeavour, and in the current fiscal context would require ruthless choices over other spending.