Why a Structural Prevention Test is needed

Scottish public policy loves the word “prevention.” The word runs through every Programme for Government since 2012, sits at the heart of the National Performance Framework, and now anchors the new Public Service Reform Strategy. Since Ivan McKee’s appointment as Cabinet Secretary for Public Service Reform, prevention has moved from background rhetoric towards the centre of the political agenda, driven by demographic pressures, the consequences of new rights and entitlements, services being overwhelmed by demand and a Scottish Government budget gap projected at 11.1 per cent by 2029/30.

There is just one problem: there is no agreement about what the word means.

Two Prevention Agendas, One Label

The Christie Commission, reporting in 2011, was unambiguous about what is needed. It called for “a wholesale systemic and political reorientation of public services” — a shift of power to communities, integration across siloed services, and, crucially, the elimination of the underlying conditions that generate demand in the first place. Christie’s prevention was about how services are organised, who holds power, and whether individuals and communities receiving public services are involved in the design and delivery of the services they use. It was a theory of institutional change, not a spending category.

The Scottish Government’s Preventative Spend Guidance, now in its second version, asks a different question. Borrowed from public health epidemiology, its primary/secondary/tertiary framework classifies spending by when in a problem’s life cycle an intervention occurs: before a problem arises, at first signs of risk, or once a problem is already established. It is a useful budget transparency tool. The intention is that Government can identify how much of the Scottish Budget goes on early or late intervention, using a shared classification that works across portfolios and organisations.

The trouble is that these two versions of what is meant by prevention are treated as if they were the same thing. They are not. One is about the timing of an intervention. The other is about its design. A programme can be classified as primary or secondary prevention under the public health model while doing nothing whatsoever to shift power, build capability, or dismantle the silos Christie was worried about. Classification is not transformation. And when the two are conflated, existing spending can be relabelled “preventative” without what is being delivered actually changing, which makes services look more Christie-aligned while sidestepping hard questions about effectiveness and value for money.

The Child Poverty Test Case

Scottish Child Payment (SCP) is the central instrument of the Scottish Government’s child poverty strategy. It reaches around 37 per cent of families with children, boosting family incomes. But under a rigorous reading of the public health model applied to child poverty as the outcome, addressing poverty via an income transfer would be classified as downstream mitigation rather than prevention.  It treats the consequence of income inadequacy rather than its causes. It is disconnected from the holistic, people- centred approach that much of the evidence suggests is required to help people lift themselves and their children out of poverty. Applying the purpose-based typology used by researchers McKendrick and Sinclair, SCP would sit in the “direct reduction” category, while in the Government’s own framing it would be “acute-responsive”. To the extent that it reduces parental stress and eases pressures on family budgets, SCP may indirectly have some preventative effects. But it is not “preventive” under either the public health or the Christie definitions

That distinction matters because resources are finite. As SCP increases — including a new £40-a-week premium for under-ones from 2027-28 — it risks crowding out the more targeted, capability-building investment that Christie’s framework would prioritise: pregnancy and early years support, parenting programmes for families affected by trauma, integrated hubs delivering place-based services in areas of multiple deprivation, and employability support that helps parents exit poverty sustainably. The latest child poverty delivery plan has introduced some genuinely Christie-aligned elements, including Whole Family Support, but these investments remain modest and short-term next to the scale of cash transfer.

Prevention and Early Intervention

The confusion over use of “prevention” extends to the way the term “early intervention” is used, often in a single paired phrase with prevention rather than clearly separated from it. In a second paper, we identify other traditions, ranging from prevention science’s universal/selective/indicated continuum to the Early Intervention Foundation model, which justifies action by child development timing and economic return, where early intervention is defined differently from prevention. In practice the two are separated by convention: mental health support for a child already in care for example is typically labelled ‘early intervention’, while parenting support for a first-time mother is typically labelled ‘prevention’, despite both being targeted, sub-population interventions. Interchangeable use of the “prevention” and “early intervention” labels, for the same underlying commitment to acting before, rather than after, harm has become entrenched, tells you nothing about whether power has shifted. A programme can be genuinely “early” and evidence-based while remaining just as centrally commissioned and professionally driven as the reactive, siloed model Christie wanted Scotland to move away from.

A Test, Not Another Category

If timing-based classification cannot answer Christie’s questions, something else is needed. That is the case for a Structural Prevention Test — a simple, deliberately non-technical check applied to spending decisions and programmes, asking three questions:

Does this shift power or control toward communities and individuals, rather than concentrating it in national programmes and professional gatekeepers? Does it build people’s capability to manage their own lives, rather than simply managing their dependency on services? And does it disrupt the siloed, single-agency way services are usually organised, rather than reinforcing it?

A programme or intervention that cannot answer “yes” to at least two of these three questions should not be classified as preventative in the Christie sense — whatever stage of the problem-formation cycle it intervenes at. This is a governance test, not a timing test, precisely the gap the public health model leaves open.

Applied consistently, the test has real bite. Family Nurse Partnership expansion looks Christie-aligned not because it happens early, but because — done well — it builds parenting capability and can be integrated into place-based, multi-agency delivery of the kind Glasgow has piloted through its Child Poverty Pathfinder and “No Wrong Door” approach.

The test is also a caution against complacency in the other direction. Capability-building language is not automatically Christie-aligned either. Asking families and communities to “build resilience” can become a way of shifting responsibility onto them without shifting any power or resource their way — the same classification-without-transformation problem in different clothing. The test only does its job if it is also applied to programmes that sound empowering.

Why This Belongs in Public Service Reform, Not Just Prevention Policy

Scotland’s fiscal position leaves no room for prevention to remain a rhetorical commitment. Seven NHS boards needed £230 million in bailout loans in 2025 despite record funding — a vivid illustration of what happens when reactive demand keeps consuming resources while preventative investment is promised but not delivered. The “wrong pocket” problem, where the part of the system that invests in prevention is not the part that captures the savings, and decisions are driven by immediate pressure to fund today’s acute demand, remain real structural obstacles. A budget classification tool, however well designed, does not resolve either of these. It was never built to.

Nor does it touch the governance culture that Christie identified as central: national politicians legislating for new rights and entitlements, thereby layering new duties and initiatives onto local delivery bodies without redesigning funding or decision-making to match, leaving councils and their partners stitching together fragmented pots of money against short timescales. Reversing that pattern is arguably the single most consequential change the new Cabinet Secretary could make — and no amount of relabelling spend as “preventative” will do it on its own.

A Structural Prevention Test applied to relevant programmes and initiatives and to major spending decisions — say, all commitments above £50 million — would not replace the Preventative Spend Tool. It would supplement it, forcing an explicit, recorded answer to the questions Christie raised, alongside the budget-transparency picture the classification tool potentially provides. Combined with a modest, ring-fenced share of preventative spend genuinely co-designed against these criteria, and a parallel set of Christie-aligned indicators tracking partnership quality, community co-design and capability outcomes, it would give the reform agenda something the classification tool cannot: method of experimentation to see what works and a way of checking not just whether spending looks more “upstream,” but whether the system is actually changing.

The Choice Ahead

The appointment of a dedicated Cabinet Secretary for Public Service Reform has created a genuine, if narrow, window. The issue at stake is not whether more spending gets described as preventative. It is whether difficult structural choices — about power, about tackling ‘failure demand’, about the balance between cash transfers and services, about who controls resources at local level — finally get confronted rather than deferred behind a more sophisticated-looking budget spreadsheet. A Structural Prevention Test, applied honestly and consistently, is a practical way to make sure that happens.

Des McNulty is Chair of the Advisory Board at the Local Policy Innovation Partnership Hub, University of Birmingham, and a member of the Glasgow Health Determinants Research Collaboration. He is also a former Chair of the Scottish Parliament’s Finance Committee. This piece draws on his June 2026 Enlighten paper, “Prevention in Scottish Public Service Reform,” and a ‘Prevention and Early Intervention: A Companion Note, ‘ published in August 2026.