Prevention is a no-brainer – so why doesn't it work?

Such is the policy question just posed on the comment on Freed blog by Sam, son of military historian Lawrence Freedman. 

Novels, we are told, operate with 7 basic plots – viz Overcoming the monster; Rags to riches; The quest; Voyage and return; Comedy; Tragedy;.and Rebirth.
This raises the interesting question of how many basic themes political leaders use for their slogans and political rhetoric. The last century would suggest the following-

• scapegoating and blaming outsiders

• taking back control

• our country the greatest

• power to the workers

• prevention is better than cure

Let's explore Freedman's post which looks at the difficulties the last policy slogan has encountered when it is attempted

A recent review of the health system by Patricia Hewitt, the former New Labour health 

minister, argues for a greater focus on preventative health. More money should be spent reducing 

the risks of illness in the first place. This would save the NHS time and money, while enabling

 people to lead healthier and happier lives.
As far as I’m aware absolutely no one disagrees with this. Some dispute the idea that it will 

save much money, as healthier people live longer and ultimately may require more healthcare 

over their lives, but no one disagrees with the basic principle that it’s better to prevent illness

 than manage its consequences.
This includes the government. The report was commissioned, and welcomed by, the Chancellor

 Jeremy Hunt. When he was health secretary his “long term plan” emphasised prevention. 

Every health and shadow health secretary pays lip service to the idea. There have been

 hundreds of reports over the years making the unarguable case. And yet since 2015/16 

the public health grant to local authorities – the main budget for preventative health - has fallen 

by 24% in real terms, even as overall healthcare spending has continued to rise. As a result

 spending in every key area of preventative health, except childhood obesity, has fallen

So despite everyone agreeing with the policy – including the person who was health secretary in 2015 and is Chancellor now – funding has been cut rather than increased. Hewitt, being an experienced policymaker, explicitly asks the “why will it be different this time” question in her report but her answers are unconvincing because she doesn’t acknowledge the fundmental reason why it keeps happening.

What explains the paradox? Why are the most widely supported things the least likely to happen? The simple answer is that if an idea is that obvious and not ideologically contested, and has featured over many years in reports and speeches, and still hasn’t happened, then the reason it’s not happening has nothing to do with support for the principle. Something else is acting as a barrier. More advocacy for the policy will not change this. As I tell the eager young think-tankers I meet, there’s no point writing another report making the case. The blockage needs to be identified and removed.
In my experience there are three core categories of barrier that prevent the obvious ideas happening: 

• spending rules; 

• misdiagnosis; and 

• fear of the electorate.

And, sure enough, the Demos Think Tank recently and obligingly sustained this argument by publishing a couple of pamphlets arguing, variously, for a “Social, relational or preventative State” with the latter arguing that

Public services are facing an unsustainable rising tide of demand. In response, politicians across the political spectrum are calling for a greater shift to prevention in public services. This is necessary: public services today are too reactive, intervening too late. To address this we need to move from transactional public services to relational public services.

Yet this essay argues that focusing on a new model for public services is necessary but insufficient, we need a state which is more expansive in how it sees the challenge of reforming public services. That’s because to truly reduce demand for public services in the long run, we need to not only prevent problems from arising, but create the conditions for flourishing and resilience within communities. Achieving this means investing in those foundational goods which create the social capital that enables us to lead better lives, without state intervention. Only then can a truly preventative state emerge.

To which, Freedman's response would undoubtedly be along the lines of

Just because something hasn’t worked, or has been blocked, in the past, it doesn’t 

mean it can’t work now. But it is important to understand the history and explain why 

it can be different this time.
The more of these discussions I have the more I have come to realise that there’s an

 odd paradox that applies to every policy area: the more obvious the idea, the less likely it is to happen. I don’t just mean obvious to me. There are plenty of policies that I personally – as a member of the dissolute liberal new elite – think are no brainers that are nevertheless hotly contested. No, these are ideas that everyone, bar perhaps a tiny ideological fringe, agree with, and that, at any of those panel events, will get a room full of appreciative nods, but nevertheless don’t happen.

This, of course, takes us back to the issue of public admin reform to whicih I will retung in another post