A recent review of preventive health policy identifies a persistent gap between rhetorical commitment and actual practices. Professors John Boswell and Paul Cairney explore an academic perspective on whether the MEPS framework can help to close the gap.
There is renewed optimism about a shift towards greater emphasis on prevention in British health policy. The Hewitt review puts prevention at the heart of effective integrated care. The government response has promised ‘a continual focus on the prevention agenda’, while Keir Starmer has a vision for NHS reform ‘where prevention comes first.’
However, we have been here before. Indeed, the Hewitt review notes that rhetorical buy in for ‘prevention’ offers no guarantee of meaningful action. There is a persistent and large gap between policy statements on prevention and outcomes in practice.
Why is this gap so large? Why does it endure despite high commitment to promote population health? What can be done to close that gap and end a dispiriting cycle of enthusiasm and disappointment?
The academic argument: the three Cs that hold prevention back
In our recent review of preventive health policy with our colleague Emily St. Denny, we describe a large and persistent gap between rhetorical commitment and actual practices. We identify three main explanations:
1. Clarity: if prevention means everything, maybe it means nothing
The language of prevention is vague. This ambiguity helps to maximise initial support (who would be against it?) but stores up trouble for later. People face more obstacles – including opposition to change - when they must translate a broad aim into tangible policy instruments.
2. Congruity: prevention is out of step with routine government business
Preventive policymaking focuses on relatively hard-to-measure, long-term outcomes. It competes badly – for attention and resources - with more pressing issues with short-term targets. Its push for radically different, holistic, policymaking does not fit with well-established rules and norms. Attempts to ‘institutionalise’ health improvement either lead to public health agencies with very limited powers, or cross-government initiatives that remain unfulfilled.
3. Capacity: low support for major investments with uncertain rewards
No policy can improve lives, reduce inequalities, and avoid political and financial costs. Rather, preventive policies involve ‘hard choices’. They are akin to capital investment: spend now and receive benefits in the future. This offer of short-term costs for uncertain long-term benefits is not attractive to governments seeking to avoid controversy and reduce spending.
Turning to the MEPS framework
In the spirit of looking for constructive solutions, we turn to the MEPS (medical, environmental, public and social determinants of health) framework developed by the NHS Confederation. MEPS offers a way to identify how persistent barriers to preventive policy might be overcome.
1. Clarity: define the problem
MEPS may help to generate agreement on how to define the problem, and use that definition to help identify solutions. It identifies four determinants of health:
Medical. Ensure that people get high-quality care in the most appropriate setting.
Environmental. Address the ‘physical, economic, commercial, regulatory’ factors that are beyond the control of individuals but that still directly impact health.
Public. Enable people to ‘make informed choices concerning their health’ (including lifestyle choices and access to services).
Social. Foster cross-sectoral cooperation to improve the contribution of relevant services to health, including housing, welfare, employment and education.
The first task is to surface and address potential tensions as quickly as possible. For example, do civil society proponents have in mind the more radical E and S determinants? Do many organisations emphasise the M and P? If so, is there a way to negotiate a common working definition?
2. Congruity: connect prevention to routine government business.
MEPS may help to generate new solutions that fit into existing ways of working:
Medical. Intervene early, identify the right pathways to care, and get it right first time.
Environmental. Focus on changing the ‘context of human behaviour’, not ‘behavioural control’.
Public. Produce ‘a clearer set of messages and priorities that need to be owned by a wider group of stakeholders and professionals’.
Social. Produce an evidence base on the health impacts of non-health services, and use the evidence systematically via accountability and finance measures.
The second task is to identify which determinants fit more closely with routine health and social care business, and which would present greater challenges or opportunities to collaborate with new stakeholders and create new ways of working.
3. Capacity: generate support for major investments with clear rewards
MEPS could underpin capacity building:
Medical. Gather and use evidence of cost-effectiveness of interventions.
Environmental. Develop more effective ways of evidencing the effects of policy changes on environmental determinants
Public. Build greater public tolerance or support for preventive policies
Social. Form alliances and pool resources with other sectors that stand to benefit from preventive policies
The third task is to identify how to produce ‘hard’ incentives to act, such as by tying prevention to funding, backed by ‘soft’ incentives ‘such as shared purpose and lasting collaboration’.
Where do we go from here?
The final step is to examine if MEPS will contribute to major changes to practice.
To foster clarity, can we establish the impact of MEPS on system-wide definitions of the problem? The MEPS framework could consolidate perspectives or simply be restating the problem and adding to the pile of approaches.
To foster congruence, how would practitioners connect MEPS to their daily routines? MEPS could perform a collective purpose or undermine it. Ambiguity serves an initial purpose, to maximise the number of interested people and invite them to participate to make sense of ‘prevention’ in practice. Then, collaboration helps a collection of organisations to make that aim more concrete. If one organisation decides what prevention means, will it make sense to its required partners and will there be widespread ‘ownership’ of this way of thinking?
Finally, would NHS and partner organisations respond positively to new capacity-based incentives? Maybe the difference here is that a key membership organisation has the leadership and convening power to set the agenda, backed by a preventive spending agenda that may oblige behavioural change.
It makes sense to explore these questions as soon as possible, rather than in evaluations years later.
Paul Cairney is professor of politics and public policy at University of Stirling. You can follow Paul on Twitter/X @CairneyPaul
John Boswell is professor of politics at University of Southampton. You can follow John on Twitter/X @Boswell_JC