Prevention: better than cure?

At Social Finance we’ve been looking at the track record of preventative services in many spheres. In the first part of a series of blogs Harry Hoare looks at barriers to funding preventative programmes.

Why don’t more preventative projects get funded? It’s surely not for lack of political interest. For decades, politicians of every stripe have been promising to transform the NHS from a sickness service to a wellness service. Meanwhile Labour MP Graham Allen’s work on early intervention has been roundly lauded by the Coalition Government.

The logic is so simple it’s got two proverbs: not only is prevention is better than cure but a stitch in time saves nine. Whilst a detailed cost-benefit analysis may find that the savings do not accrue at an exact 1:9 ratio (it might even be greater), there is increasing evidence across crime reduction, children’s care and drug recovery that preventative programmes – programmes that attempt to intervene early to prevent problems growing – have the potential to generate significant savings for Government.

So why haven’t we witnessed a national roll-out of prevention? Maybe it’s political short-sightedness. Maybe more acute problems take priority. Sometimes, even, conservative professions might prefer the status quo.

Rarely do those managing preventative services get the blame.

Yet if one looks at the track record of many preventative programmes in recent years an interesting pattern starts to emerge, which should start to raise some questions about how many preventative services are run. Performance of most preventative programmes is incredibly variable. Perhaps, they don’t get funded because backing such variable services is not just expensive, but also risky. Variation in outcomes is by no means the preserve of preventative services but there may be factors that make poorly implemented preventative programmes more liable to produce bad results.

Government, rightly, has a duty to spend our money wisely, on programmes that have been successful in the past and to manage the risk of funding costly new programmes that may not achieve the desired outcomes.

Crime Reduction Programme

Some years ago, the Home Office launched an ambitious £250 million crime reduction programme over a three-year period with the aim of taking an evidence-based approach to preventing crime. The programme was beset by multiple problems from recruiting qualified staff to project management and there is a large literature documenting this ‘implementation failure.’ Evaluators point to low levels of programme fidelity and high staff turnover as causes of the programme’s lack of success.

As a result, the outcomes showed significant variation with negative results in a third of areas in which crime increased over the same period. If implemented well, savings from a crime reduction policy can generate cashable cost savings that exceed the cost of the programme.

Teenage Pregnancy Strategy

The Government launched a concerted national campaign of improved sex education, access to contraception and programmes to help teenage mothers return to education, training, or employment (ETE) in an attempt to bring down the UK’s high teenage pregnancy rate. Overall £250 million was spent between 1999 and 2008.

Good results have been patchy. Whilst there was an overall downward trend in the under-18 conception rate of 11%, this falls far short of the 50% reduction target and the absolute number of teenage pregnancies has risen in as many years as it has fallen.[1] An independent evaluation notes ‘considerable variation in progress around the country. Some local areas have applied the Strategy very successfully and reduced their under-18 conception rates by more than 26%. A few other areas have failed to make any impact and their rates remain relatively unchanged.’[2] London, for example witnessed increased teenage pregnancy rates in some areas[3] and there is ‘marked regional variation’ in the ETE outcomes across the country.[4]

Budget-Holding Lead Professionals (BHLPs) in Children’s Services

The Government ran a series of pilots to test the effectiveness of the BHLP model in the UK following the success of policies in the US. Wraparound Milwaukee allowed BHLPs to commission additional services for children and young people with additional needs so that the decision maker became the budget holder.

The results of the UK pilots were very disappointing. ‘School attendance was just as likely to worsen in respect of children and young people in the BHLP sample as it was to improve.’ [5] Furthermore, attendance actually decreased (by 0.7%) for each additional £1,000 spent on statutory and voluntary sector services for children. ‘With the benefit of hindsight, some pilot managers acknowledged that the BHLP pilots had at that particular time constituted a step too far.’[6]

The pilots were implemented during a time of change for children’s services and failed to achieve anything near expected outcomes. The episode demonstrates that a good evidence base from is no guarantee of good outcomes.

Programme Variation

When one thinks about it, such variation is unsurprising. The problems which preventative services seek to tackle are often inherently complex. There are long chains of causality between intervention and outcomes and this means that those delivering programmes often get little feedback on how well they are performing, because impact is not apparent for some years or simply not systematically measured. It you are a poor heart surgeon, it will be very quickly obvious to you and your managers if more patients are dying than typical. If you are a poor social worker, you may not face the same scrutiny.

For us, the test of good social investment in prevention, such as through Social Impact Bonds, is therefore not just about whether it provides greater funding for prevention per se. It is equally about whether they can reduce such variations in performance. In order to reduce programme variation, controllers need a good strategy for managing implementation risk.

Social Finance will be exploring the issues surrounding funding prevention, management of implementation risk and the value for money of social impact bonds in the run up to hosting a conference in June 2012.

By Harry Hoare, Analyst at Social Finance

[1] The Monument Trust, Reducing teenage pregnancies and their negative effects in the UK (2009)

[2] Teenage Pregnancy Independent Advisory Group Annual Report 2008/09 (2009)

[3] Final Report, TPSE Teenage Pregnancy Strategy Evaluation (2005)

[4] Teenage Pregnancy Independent Advisory Group Annual Report 2008/09 (2009)

[5] Budget Holding Lead Professional Pilots in Multi-Agency Children’s Services in England National Evaluation (2009)

[6] Ibid.

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One Response to Prevention: better than cure?

  1. Pingback: Prevention: risky business? | socialfinanceuk

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