John Copps asks what we can do to rebalance government investment towards preventing problems rather than crisis management and is optimistic that 2024 can be the start of a journey of change.
What is the most difficult issue in public services today? This is a question that I found myself debating with colleagues last week as we contemplated the year ahead.
Everyone agreed there is no shortage of contenders: the rising number of children in care, NHS backlogs, access to GPs, public sector workforce shortages, and the crisis in adult social care. These are all huge and difficult problems.
But my vote went to something more technical, about the mechanics of how services are funded and the way government works – but which I believe underpins many of these other contenders: how do we invest in preventing problems whilst also dealing with those problems at the same time?
For me, this question hangs around all debates about public service reform. Most of the issues we face start with fact that acute need and ‘crisis events’ hoover up all the time and resources, and there is little remaining to tackle what causes them in the first place.
This focus on crisis is visible everywhere. Back in 2019, the NHS Long Term plan called for a redistribution of funding from acute to primary and community care. Instead, spending on acute care has grown faster than any other area of spend. Elsewhere, the 2022 Independent Review of children’s social care found a system ‘increasingly skewed towards acute services and away from effective help’.
Why is prevention so difficult?
Prevention is better than cure is a maxim that almost everyone in public services ascribes to. The case for it can be built on sound economic arguments around ‘invest to save’, as well as moral and humanitarian principles. But it remains stubbornly difficult to do. Why?
In today’s context, to provide adequate preventative services requires three related things. First, channelling money into prevention at the same time as continuing to fund crisis services. This ‘double-running’ means more resources and a higher cost in the short term. Second, long term commitment. This is because preventative services take a while to ‘kick in’ and have a measurable impact. Third, having people and organisations that value prevention and are rewarded for it. This must be hardwired into structures and incentives – it is not enough just to hold a general philosophical belief in it.
1. ‘Double running’
Public sector budgets are squeezed like never before. Local government is in financial crisis and the NHS goes cap in the hand to the Treasury every winter. However good intentions are, finding money to invest is tough when there are immediate pressures – and ones that are a statutory responsibility.
If cash isn’t available from existing budgets then another route might be to borrow it. But local government is prohibited from using lending to fund revenue costs, whilst NHS trusts must obtain permission from the Department from Health and Social Care. Social finance – in the form of social impact bonds (not actually bonds but rather payment by results contracts between investor and government) – was once hailed as the great hope but hasn’t fulfilled its early promise.
Another solution is for central government to be more generous. The appetite to do that through increases in general funding settlements is not there. An alternative response is to establish programmes or funds, where departments commit resources to be distributed locally. Look back over recent years and we’ve had lots of them – the Troubled Families Programme (now Supporting Families), the Early Intervention Youth Fund and the Long Term Conditions Early Intervention Programme to name a few – most arguably not of a size to make a significant difference. For this strategy to work it needs to be at scale, perhaps more like the ‘Emergency Better Health Programme’ to tackle smoking, obesity and heart disease proposed in ‘A Covenant for Health’.
2. Thinking and committing long term
To invest in prevention is to invest in the future. That means benefits might not be seen for one, three or ten years. By that time, the person making the decision today may be in a different job and is unlikely to get the credit. And for them it means sacrificing immediate wins.
In a recent series on BBC Radio Four, serial government troubleshooter Dame Louise Casey, talked to former Scottish First Minister Nicola Sturgeon about her success at steering a cross political party consensus around early intervention for children known as ‘the Promise’. Sturgeon reflects on the fact that people will always be tempted to ‘go for the stuff [that is] visible and easiest to demonstrate success around’. She then explains that ‘the reasons politicians don’t make the choice to focus on the really difficult stuff is that… often you have to deal with a period of failure’.
The point here is that investing in prevention is likely to require a hard choice about what we are not going to do (as well as what we are going to do) and then sticking at it through tough times. In practice, this is easier with at least some degree of consensus.
3. Valuing prevention
As well as having sound economic and moral arguments to invest in prevention, we must also pay attention to the incentives on people and organisations.
One issue is a lack of parity between the status of different types of work in the culture of professions. Within medicine, for example, being a doctor in a hospital tends to have more caché than being a GP in the community. Similarly, in social care, it is the ‘hard end’ of the profession that garners the status and reward. This matters because it steers many ambitious people to crisis services and means they often shout louder. Is there a way to create more parity?
For organisations, financial flows incentivise certain behaviours, often overlooking the benefits of prevention. For example, take the case of a patient that smokes heavily, is overweight and has type 2 diabetes. Support in the community to help that person quit smoking, lose weight and reverse their diabetes is likely to prevent many trips to hospital. But there is no financial mechanism for recognising that potential saving to the hospital and use it to pay the salary of a community nurse or health worker. You could write the same story for the issues around poverty, poor housing and debt that impacts families in the care system. The result is that too little prevention activity, too many expensive A&E visits and too many children entering care.
Where do we go from here?
Being able to invest in prevention is a problem that stands out across a wide range of public services. But as is often the case, identifying the problem is easier than finding a solution.
As the discussion above shows, there isn’t going to be a single answer – we need a combination of political will, resolve from public service leaders, reform to funding flows, and a vision that professions and the public can buy into. This will be hard work but there are reasons to be optimistic.
We are in a General Election year so that should focus the minds of politicians, as well as start the gun on government term of (at least) five years. Collaboration between public services is picking up pace – through Integrated Care at 'system' and 'place' level, and devolution of power to local areas. Shared governance structures are now more commonplace, breaking down some of the barriers between organisations, and budgets are creeping towards closer alignment. With the memory of the pandemic still fresh and an awareness of the challenges public services face, both professionals and the public are receptive to new ideas. Digital technology can play a bigger part in connecting people with public services in their community.
Our public services leaders must now be brave. If investing in prevention is the right thing to do then together they have to find a way – as we all stand to benefit in the long run.
To read about Mutual Ventures' work on public services reform in 2024 click here.