The problem with prevention

Prevention has become a bit of a buzzword. As public services struggle to meet demand alongside widespread funding cuts, increasingly people are recognising the need to focus on the factors that lead people to these services in the first place. The NHS is a classic example – current pressures have led to prevention becoming embedded in the everyday health lingo. So what’s the problem?

We need to start with assets not deficits

The problem with a focus on prevention alone is that it can put issues such as people’s health firmly in the box of something to be ‘solved’. The WHO defines disease prevention in terms of “interventions” to “minimise the burden of disease and associated risk factors.” This kind of language can entrench health in the medical model and can lead conversations into illness, unhealthy behaviours and costs to the NHS. Far from seeing health as something to invest in, as you are perhaps more likely to hear in the context of jobs or training, poor health can simply be seen as an outcome to prevent. But there are welcome shifts underway. For example, recognition of the need to measure the positive as well as the negative things that people accrue through life that contribute to their health. There is also work underway to explore the role of health as an input, not just an output, of thriving places with positive social and economic outcomes.

Service-focused responses need to open out to a wider systems focus

The prevention frame can lead into the trap of focusing on preventing problems, using only the processes within services, rather than looking more broadly at the wider system. In the case of health, the service-level “problem” to prevent is overwhelmingly presented as the strained finances of the NHS. This can lead to closed conversations that focus on service-based cycles (like the Five Year Forward View) and do not adequately involve organisations or people outside of the traditional health sector.

In the case of issues like obesity, this tends to lead to short-term medical interventions or education campaigns designed to address so-called ‘lifestyle behaviours’ – namely eating less and moving more. This approach neglects expertise in the wider system and the role of social determinants of our health such as housing, transport and education. A systems approach looks at the factors in our environment that lead to unhealthy behaviours in the first place, looking to create a new system rather than prevent linear causal relationships. This might mean addressing anything from transport infrastructure to insecure housing tenancies.

Professionals need to shift the focus towards people

A conversation that moves beyond the deficits of illness and health services will likely lead to an approach that focuses on people as people rather than treating them as “patients” defined by their illness, or “clients”, defined by their service needs. While this might not be out of place in A&E or a GP surgery, hierarchical and transactional relationships can exclude and prevent constructive and creative conversation. Innovation in local government is demonstrating a new approach, with implications for health. There’s a reason why Wigan’s Community Investment Fund isn’t called a Community Prevention Fund – it engages people across Wigan to apply for funding, not to prevent Wigan’s problems, but to work towards longer term goals and ambitions that matter to the community. It forms part of The Wigan Deal, an informal contract between the council and residents to work together to make Wigan Borough a better place to live and work. Similarly, Stockport Council are taking an asset-based approach in their family-facing services – staff are trained in strengths-based conversations, which for example begin with “what matters to you?” rather than “what’s the matter with you?”.

The long-term sustainability of the NHS requires a conversation that doesn’t start with preventing its problems. Current demand and funding pressures make this a challenging time for change, but new ways of talking about and, in turn, ‘doing’ health are on the rise. These conversations start with the value of good health, wider systems and local knowledge not the deficits of patients, clients and services.

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