3 April 2015

The Economics of Prevention and Difficult Decisions for Community Planning Partnerships in Scotland

Claire Bynner, Research Associate at What Works Scotland, reflects on a seminar held by What Works Scotland last week on the Economics of Prevention focused on community planning and health.

This blog summarises the main points from the seminar and concludes that evidence provides no easy answers for CPPs.

 The Viva
“The Viva - 1894" by Henry Jamyn Brooks at the Royal College of Physicians and Surgeons

It seemed somehow fitting that our Economics of Prevention seminar should be held in a wood panelled room at The Royal College of Physicians and Surgeons, a venue where learned men grappled with the scientific problems of the past. Today’s policy problems, in contrast appear infinitely more complex, namely how to respond to widening inequalities and budget cuts while at the same time reducing the need for crisis intervention and ‘social surgery’. Since Christie (2011)  the policy theory as been that public services should prioritise those interventions that are most likely to prevent negative outcomes from arising in the first place. The belief is that this will lead to more equitable outcomes and cost savings over the longer term. The focus of this seminar was to examine the economics of this theory of prevention.

Ken Gibb from What Works Scotland explained how ‘thinking like an economist’ can help decision-making. He described ten key concepts in economics that are relevant to decisions on prevention (with recommendations for further reading - see below). The problem for mainstream economics is that people often don't behave as rational, individualistic, economic agents and behavioural economics can help to explain why. Can we shape prevention interventions that are more consistent with behavioural ideas? Finally Ken delivered a message that might be difficult for those seeking immediate answers to prevention, arguing that the complexity of influences on behaviour makes it exceedingly difficult to accurately predict pathways from interventions to outcomes. These causal pathways are inevitably complex and uncertain.

Neil Craig, Principal Public Health Advisor at NHS Health Scotland acknowledged the problem of gaps in the evidence base. However he argued that the evidence is clear in one regard: the most cost effective approaches to reducing health inequalities are at the societal level of fiscal decisions, regulation and legislation. However the operational focus of CPPs is on individually- based approaches to behaviour change. In this area the evidence of prevention measures leading to more equal health outcomes is mixed. Those with higher incomes are more likely to adopt the behavioural change desired. Neil was less optimistic than Christie (2011) regarding the cost savings from prevention. Cost effectiveness can be achieved through prevention approaches but prevention is unlikely to achieve savings that can be simply reinvested elsewhere.

In response to the previous speakers, Peter Allan of Dundee Partnership said that in a context of limited resources and high demand for crisis services, it was important to get beyond the idea of prevention as simply about stopping things from getting worse. Peter felt that the public sector has a culture of investing in negative outcomes. He described how frontline officers can tell you which families and streets are likely to have problems, however no intervention or action is taken, instead people are told to “come back when you’re worse…”. In Dundee, community planning partners have been developing a joined-up approach to prevention illustrated in the diagram below. This approach aims to break the red cycle of negative outcomes by focusing on sustaining improved outcomes and on moving towards the green cycle of positive outcomes without slipping back into the red. Recovery-based Prevention in effective means turning crisis services into services that focus on recovery.

 A range of other preventative approaches were mentioned in the discussion including work on: Mitigating the impacts of welfare reformearly years programmes; and reducing social isolation through social prescribing (for example the Links Worker Programme).

A prevention mindset could become embedded into budgeting with new initiatives having a stronger preventative element. Some argued that calculations about winners and losers from prevention decisions should be made more explicit. Political support will be needed to prevent the loudest (middle class) voices from dominating and having their interests being met while poorer communities compete with each other over reduced resources. However at the same time there is a need to keep the middle classes on board to protect services and put a floor on cuts. Participatory budgeting (PB) has the potential to increase the public understanding of preventative decisions and public finances but we need to provide the space to train and educate citizens in the new responsibilities PB brings. There is also potential for improved joint working at the front line and for officers to have greater authority and support to take preventive decisions. Can we get to the point where performance is measured not in terms of service targets but in terms of decisions that prioritise prevention?

CPPs felt the need for practical actions and positive steps towards prevention which they could take in the short to medium term and the need for greater political support for the difficult investment decisions that lie ahead. While accepting that the evidence provides no easy answers for CPPs, an indecisive and weakened public sector would be a further injustice to the communities who are already suffering the worst effects of the financial crisis.

Further information/publications:
  • Christie Commission. (2011). Commission on the future delivery of public services. Edinburgh www.scotland. gov.uk/Publications/2011/06/27154527/2
  • Ha-Joon Chang (2014) Economics: The User’s Guide. Pelican: London
  • Avinash Dixit (2014) Microeconomics: A Very Short Introduction. Oxford University Press: Oxford

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