Shifting public services to focus on prevention: Impediments & implications

What Works Scotland Directors James Mitchell and Ken Gibb examine prevention and what stands in the way of making progress in a shift to prevention.

There is a consensus that the Christie Commission’s emphasis on shifting to prevention is the right direction of travel if outcomes are to be improved for people and communities and reduce future demands on public services. There is also a consensus that this is not happening at the pace desired.  What stands in the way of progress? How can it be overcome?

We have found that the well-established public-policy framework of Ideas, Institutions, and Interests, is a useful way to frame this discussion. In developing work in this area, we have also interviewed practitioners across a range of services. Taking each of the three ‘I’s in turn we can identify key impediments.

Ideas 

The academic literature distinguishes between different forms of prevention: primary, secondary and tertiary or upstream and downstream [1].  Practitioners often do not see these distinctions as important – preferring early focus on a problem or issue and how it can be addressed at this  stage.  It is not so much the idea of prevention that is contested as where prevention sits alongside public service activities.

Prevention is only one amongst a number of public service ideas and not always the priority in service delivery.  Prevention competes with policy enforcement, prioritizing between short run policy choices, responsive policy, and crisis management for the attention of policy-makers.  Each of these is important and no serious policy-maker, at local or national levels would place more emphasis on prevention if it meant abandoning any of the others.  In many cases, these distinctions break down.  Almost all policies can be presented as having a responsive element.

In policing, for example, the enforcement of a law may ensure that future infringements are prevented.  Triage nursing, as with any triage approach in public policy, is defined as early assessment in order to identify priorities.  Done well, it involves preventing the deterioration of an existing condition.  Crisis management is similar.

The emphasis on prevention needs to be set alongside these other ideas and demands.

Institutions

It is long well established that institutions have path dependent properties ie it is very difficult for any institution to change course once working practices have been established.  Institutions adopt practices that become deeply embedded.  A significant change of emphasis may sound simple but exhortation is not enough.  Familiar practices become engrained norms.

Not only are practices engrained but we currently set short- to medium-term goals and targets that place little, if any, emphasis on long-term prevention.  As the long-term is little more than the combination of short-terms, then we can hardly be surprised that our long-term goals are not met if short-term goals are different from long-term goals.

A fundamental shift to prevention will not be easily achieved even when a consensus exists to move in that direction. 

Adopting or giving greater priority to prevention when public services are already under pressure raises questions as to how this shift should occur and who will take the lead.  Prevention may be the better approach in the long term but Keynes’ famous comment is apposite, ‘in the long run, we are all dead’.  In the short and medium term, public services must address immediate challenges.  Public service is judged by the immediate.  Punishments, plaudits and promotion are all awarded in response to recent past and immediate activities.  Prevention will often involve a shift across a range of public services and it will not always be easy to identify culpability for the failure to make the shift or credit when it is achieved.  Our public services are judged in terms that make it very difficult to prioritise prevention.

To put it crudely, there is little credit for prevention.

Interests

This brings us to interests.  It is in the collective interest to shift to prevention but not necessarily, at least in the short term, in the interest of any single institution.  In a world of tight public finances, a shift in resources (whether money, time or effort) involves a cut elsewhere.  Everyone looks to everyone else to make the shift and progress is not realised.  We face the familiar prisoners’ dilemma.

And the game-theoretic ideas can be extended usefully. A non-co-operative structure of inter-institutional relationships may be frowned upon, but it would be naïve to think that this never can occur. Nor would it be sensible to ignore the possibility of non-altruistic behaviour by senior bureaucrats in such circumstances. How do we move towards a co-operative game, one in which opportunities for prevention and collaboration are encouraged and rewarded?

Implications

So far, the message is bleak.  We want a shift to prevention but are unable to effect it, at least at pace.  But acknowledging what appears to be a bleak situation is the first stage towards addressing the challenge.

Three responses are proposed:

1. Ideas and mindsets in training and workplace.
2. Incentivise a shift to prevention and disincentivise other practices.
3. Force the pace by removing institutional impediments. 

Ideas and Mindsets

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 emphasized or even mentioned?  Leadership plays an important part in this.  If the message from the top is not on prevention then the behaviour through any service is unlikely to give it priority.  There is a need to consider the extent to which the very idea of prevention is given anything like the place it ought to be given.

All public services would be well served by conducting an audit on prevention in its internal messaging. This should include an internally managed but participative mapping of the types of spending and activity undertaken by the organization to encourage creative thinking and identifying prevention organically.

Institutions

Our institutions operate in silos in which each looks to others to lead on prevention.  This is most evident in the financial silos that operate within public services.  It is frequently asserted that a shift in resource towards prevention by one institution will only benefit others.  This relates strongly to the above observation on short-termism and non-co-operation.

Current institutional arrangements rest on the hope that different institutions will find common cause in pursuing common long-term objectives.  This might happen but it runs contrary to immediate rational behaviour.

There needs to be an examination of short- to medium-term goals and targets.  If the emphasis here fails to permit space for prevention then we should not be surprised if there is no shift to prevention. From the outset of collaborations, inter-agency activities and joint projects, the mindset and priority of prevention needs to be embedded by leaders and in the work of their staff. It should be a fundamental aspect of any inter-organisational working. This, rather than focusing on outcomes over a defined period, is where the decisive shift to prevention may actually occur – in the embedding of processes that will, over time, achieve a range of prevention benefits.

There needs to be a closer examination of the goals and targets set to ensure an emphasis on long-term at the expense of short- to medium-term efforts.

Interests

Aligning interests and objectives may seem obvious but currently there is little effort to do this. The suggestion is that we need to think again about the set of rewards and incentives for pursuing prevention that are used to encourage public service workers, organisations and collaborations between agencies. Is there a public sector equivalent to something akin to a private sector consortium savings pool where contractors can share in savings made by cutting costs against targets?

NOTE

1. See: P.Hardiker, K. Exton, and M. Barker, Literature Reviews: Crime Prevention and Prevention in Health Care, University of Leicester, Report for the Department of Health 1986.