What Works Scotland/NHS Health Scotland’s second seminar on the Economics of Prevention, on 28 May 2015 at The Lighthouse, Glasgow, brought together over 45 participants from national and local public bodies and the third sector.
The main aim of the event was to explore some fresh perspectives and understandings as to what works in prevention by bringing together perspectives from a range of sectors. Three key areas were explored: policing, health and housing. Presentation slides are available on the What Works Scotland website and the blog on the first Economics of Prevention event.
Professor Nick Watson from What Works Scotland opened the seminar by challenging us to think again about prevention. He reminded us that seeking to reduce public spending is only one potential purpose of prevention – improving health, wellbeing and social justice are part of the purpose too. More ways of seeing prevention were drawn out through the case studies from three very different areas of public service.
Chief Inspector Alastair Muir discussed policing and prevention in the context of refugees and asylum seekers in Glasgow, some of whom came from backgrounds in which the carrying of knives was accepted as an approach to self-protection. Painstaking work with these groups had enabled the police to develop trust with new communities and be able to talk with them about knife crime in Scotland and laws related to carrying knives, and also about their rights to protection from hate crime: the police were seeking to prevent knife crime through ‘upstreaming’ the intervention. The police had also linked the United Nations in Scotland group of refugees and asylum seekers in Glasgow with a local group of men in recovery, the groups finding commonalities. This approach sought to minimise the potential for misunderstanding between groups and again reduce the potential for knife crime and help to tackle racism: another preventative approach. Whilst it is impossible to specify the financial savings as these actions sought to prevent specifically unknowable events, Alastair noted that one murder costs millions of pounds to investigate. For Alastair there remained the problems of sustaining this preventative work in the context of police staff reductions, of mainstreaming this type of work, and how to better capture evidence of this type of preventative policing.
Rebecca Campbell, Health Improvement Lead (tobacco) from NHS Greater Glasgow and Clyde and Professor David Tappin, University of Glasgow spoke about their work in providing financial incentives to stop smoking in pregnancy, as recommended by NICE to improve quit rates. It is about protecting the wellbeing and longevity of both mother and child, so is preventative, as well as being aligned with Government policy seeking a smoke free Scotland by 2034. They reported that smoking during pregnancy is also the most avoidable cause of foetal and infant ill-health and death. By providing financial incentives of £400 in addition to normal interventions, quit rates improved from 9% to 23%, with increased birth weight of 150g for those extra 14% of children, thus improving both mother and child’s life chances. This intervention was very carefully costed and was found to be cost effective and fully meet NICE Guidelines. The discussion following the presentation raised concerns about the morality of financial incentives for this type of prevention – should we for example pay people to eat fruit and vegetables or stop drinking alcohol? The savings from prevention of alcohol-related violence could be considerable. Professor Tappin argued that ‘we have evidence that this works … the only challenge is whether it makes a difference to the health of the population’. So, prevention is not simply morally neutral – it can involve ethical choices.
Dominic Munro, Head of the Better Homes Division, Scottish Government, argued that prevention can be turned on its head, and be considered in terms of ‘doing good’ as much as ‘preventing bad’. Good housing can help to prevent a range of bad outcomes. Adapting homes can reduce the burden on the NHS, including reducing delayed discharges. £1.5bn is spent on unplanned admissions by older people; by reducing the chance of falling at home some of this cost and harm will be prevented. This demonstrates how prevention actions in one service area can lead to cost savings in another. Further, £1m spent on energy efficiency helps cut energy bills, releasing c. £3m into the economy. And energy efficiency also contributes to prevention of climate change, with £1m spent on reducing carbon emissions saving c.12Kt of CO2. So, the concept of prevention can include prevention of global warming, again in line with Scottish Government strategic objectives. The Better Homes Division were facing comparable dilemmas to the quit smoking initiative in terms of giving people loans and cashback vouchers to improve the efficiency of their private homes, so as to contribute to preventing climate change: paying people to do good things.
So, a number of ways of seeing the economics of prevention were raised by the presentations and discussion. These included:
- Prevention need not only be thought of in terms of seeking to save public funds (the narrow economics) but is also about preventing social injustice and environmental harm, so increasing human flourishing.
- Is there space to reframe what prevention means, so making it more publicly amenable to shift public and charitable resources in this direction? There is a political challenge here, particularly in relation to health and policing where reactive services tend to make the news headlines.
- There remains a lack of clarity of the underlying theory and evidence, including causal chains, time scales between intervention and cost savings, and degree of exhaustiveness in calculation.
- How do public bodies manage the tension - or indeed synergy - between the costs of preventative approaches taken by one service achieving prevention benefits for other services (for example, a health intervention to reduce smoking also reduces the chances of accidental fires, releasing fire service resources)? Hastings et al (2015) recommend that the means be found to allow the benefits of prevention to fall back to the service that has borne the costs.
- Is it better to think about prevention as a spectrum rather than a binary: a reduction of or increase in preventative activities, rather than ‘prevention’ or ‘not prevention’?
- The Early Action Task Force convened by Community Links in East London, argues that it is easy to make excuses not to do prevention, and suggests starting in a rough and ready way, setting quite minor incremental targets year by year. Make it simple. Evidence is always imperfect, so start somewhere.