Preventing failure
How to build a Preventative State
“We will reinvent the NHS through 3 radical shifts: hospital to community, analogue to digital, sickness to prevention” - Fit for the future: 10-year Health Plan for England, 2025
“A new approach to benefit rules for young people, to make sure they can develop skills alongside searching for work, while also preventing young people from falling out of the workforce before their careers have begun” - Get Britain Working White Paper, 2024
“Our end goal is for rough sleeping to be prevented wherever possible but when it does occur, it must be rare, brief and non-recurring.” - Ending Rough Sleeping For Good, September 2022
“Rather than focusing on approaches to delivering care that intervene at a time of crisis, care and support services should intervene early to support individuals, helping people retain or regain their skills and confidence, and prevent needs from developing.” - People at the Heart of Care: adult social care reform, March 2022
“We will address the underlying drivers and enablers of drug production and trafficking upstream including strengthening our prevention work and increasing the resilience of people” - From harm to hope: a 10-year drugs plan, 2021
“It needs the support of communities thinking about what they can themselves do to help prevent violent crime happening in the first place” - Serious Violence Strategy, 2018
“Prevention is better than cure, and we are investing heavily in preventing crime.” - A Five Year Strategy for Protecting the Public and Reducing Re-offending, 2006
“Preventing terrorism by tackling the radicalisation of individuals” - Countering International Terrorism: The United Kingdom’s Strategy, 2006
“This requires striking an appropriate balance between different types of care – in particular, between health and social care, between primary and secondary care and between treatment and prevention.” - Securing our Future Health: Taking a Long-Term View, Final Report, 2002
(Emphasis added)
For decades government strategies for public services have been anchored by the idea of prevention: reducing the demand for support from the State through intervening early and stopping the public needing them in the first place. It is a staple of public sector reform doctrine.
The argument is intuitive– the cost of many public services is growing faster than the economy can afford to bear, driven by long-term trends like an ageing population and shorter-term crises like the Covid-19 pandemic. Something needs to change, and if policymakers could prevent lots of people needing services in the first place then that would be a big win. Not just for the taxpayer, but for the public themselves – reduced demand for public services tends to mean reduced harm and better outcomes overall.
But in the decades of arguing the policy case, not much has changed on the ground. Few public services have changed much, most of the public still only experience them in the most acute and severe cases, and the growth in spending has almost entirely gone towards managing demand rather than getting upstream of it.
If there is such a strong policy consensus on the need for the State to be more preventative, but it isn’t happening in practice, then what’s going on? What is everyone missing?
To find out, we ran a series of roundtables and workshops last year with policymakers and public service leaders to discuss the challenges with making the shift to prevention in their areas, and how to fix it.
The unanimous consensus in favour of prevention hasn’t survived contact with reality. Not because of a lack of goodwill, but because it failed to force the kind of systemic changes to how the State works which would underpin a preventative approach. Government isn’t set up to switch gears from one orthodoxy to another overnight, and getting it to do so involves hard trade offs which the theory of prevention hasn’t had answers to.
Where should we focus preventative investment – on ‘population-level’ interventions, or targeted cases which are much closer to contact with public services?
Do preventative approaches really need ‘whole of government’ approaches to coordinate? And if there are limits to how feasible those are, are there easier areas they can target which are much more narrowly focused on prevention within the gift of individual services?
Is it realistic that the government will ever have billions of pounds more to spend on preventative programmes, on top of existing levels of spending? And if not, how do services shift the balance of their work incrementally?
These are just some of the questions we answer in our summary paper Building the Preventative State, published today.
Across the board, it feels like many advocates for prevention have let the perfect be the enemy of the good – arguing for idealised versions of the policy which aren’t realistic about the constraints of the public sector, hampering them from making more incremental progress. This isn’t an uncommon challenge in the State – there are other areas like prevention, where the uncritical embrace of good policy ideas means they don’t develop the important nuances which help further them in practice.
It’s been a pleasure to partner with the team at Newton to put this series on as part of our ‘Re:Imagining Whitehall’ programme, along with the 100+ public, private and third sector leaders who joined the discussions.