Five reasons why we will never scale up prevention

Simon Stevens is giving prevention a radical upgrade. 

This is excellent. I hope he is successful, and I will support him in every way I am able to.
Richard Smith recently blogged on why we never quite manage it….

Why does prevention always come behind treatment of disease?

Two key issues (Berwick)

1)prevention – in contrast to healthcare – lacks “a corporate voice”; and 2) the science behind prevention is undeveloped.

Maybe local government can help balance the 30yr historic imbalance in the former these issues. 

The latter – the research base – is tricky. Many research paradigms – scientific, political, sociological, individual level vs social policy interventions. Not an easy one when everyone wants the reductionist evidential bullets.
There’s oft an excuse about poor evidence and return on investment. Really? REALLY? fraid I don’t buy this, at all. My stock response is something along the lines of …..” So you question the evidence of return on investment to prevent teenage pregnancy, stop smoking or active travel yet continue to pour hundreds of millions of pounds into service xxxxx and you don’t actually know whether that’s a Valuable?” 

The asymmetric thinking on ROI is everywhere!
Here I offer some other reasons why we may never acheive the radical upgrade. Some of these are very solvable indeed.

The financial framework favours status quo. Definitively in health service, the financial framework incentives ‘doing more’ health care.

This point is particularly geared towards health service viewpoint on “prevention”

We are probably at or over the peak of diminishing marginal returns in many areas of health care. Delivery of more care will not yield high returns in terms of outcomes. There’s no incentive financially speaking to prevent anything.


The regulatory framework and system performance targets skew activity towards meeting current need promptly rather than preventing future need.


The prevailing mindset favours status quo – when was the last time you read a business case that said ‘this will reduce cardiovascular mortality by 25%)

The infrastructure is geared towards treating stuff not preventing stuff. I’m sure you’ve read lots of documents that want funding to deliver more care (with the promise of savings somewhere).


There isn’t a single thing. The magic bullet doesn’t exist.

There are a number of sub components to this

We all want the magic bullet. It doesn’t exist.
Often I’ve seen ‘public health etc’ in the box on the planning framework where ‘prevention’ initiatives is supposed to be detailed. 
Services for individuals versus policies for an enabling environment.

We arguably over focus on “delivery of services to people” to prevent stuff, and under focus on supporting people to support themselves, and definately under focus on public policy ideas to shape the environment in which we make choices.

We use very mixed and odd narratives and languages to describe prevention. Everything from “prevention early death” through “preventing unscheduled admission” to preventing illness happening in the first place and promoting health and well being, and many other concepts beside are all classed as “prevention”. 

We muddle screening and early diagnosis with “prevention”

Our narrative needs to be clearer – what is it we are trying to prevent?
It’s interesting to reflect on the role of PH in NHS the focus was (MOSLTY) to help NHS meet pop health need. In local govt the focus on health outcomes. Both needed, but v different.

This is all fairly straightforward…..I hope we will see progress. Yes, Everyone is really busy. The “I’m too busy to “do all this prevention stuff”” is common.
Yes sure everybody is really busy & it’s ‘someone else’s job’. If that always remains the case we will never achieve the ‘upgrade’ needed.
Upgrading needs a command to get people get off that conveyor belt, to stop & think. The reality of here and now demand is in our face & overwhelming.


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