Prevention has become a watchword for Scottish Government publications, taking a central role in strategies like the Population Health Framework and the Public Service Reform Strategy. The Scottish Government Prevention Unit has been established to drive forward more unified thinking about Scottish Government’s approach to prevention. Last week, they put out several publications laying out how Scottish Government defines prevention, reporting on a pilot budget exercise to identify preventative spend, and several tools for analysing preventative budgeting and prevention more generally.
Essentially, prevention (as opposed to reactive policy) aims to stop or reduce problems before they start. The first of the new Scottish Government publications defines prevention in three levels, which are now familiar in the public health sphere:
- Primary Prevention: Population-level action, or action which targets a large subset of the population, to build resilience and stop known risks from developing into problems
- Secondary Prevention: Targeted action to identify and respond to early signs of a problem to prevent escalation
- Tertiary Prevention: Intervention once there is a problem to stop it from getting worse or recurring in future.
Primary and secondary prevention are more “upstream” (an earlier intervention) and intended to reduce the need for “downstream” provision of services that simply respond to existing problems. The latter is sometimes called “failure demand”, since it reflects service demand that arises when more upstream interventions have failed or are absent.
These are similar to definitions of prevention to those used by Public Health Scotland (PHS) and the Scottish Health Equity Research Unit (SHERU), with a few semantic differences.
A recent paper from Enlighten criticises the Scottish Government definition for not reflecting the Christie Commission’s recommendations, which include structural transformation, and for defining tertiary prevention to cover what others might call reactive policy. These criticisms may be valid, but as SHERU colleagues have pointed out in the past, it will not do to get bogged down in definitions – the Scottish Government has presented their definition and should now focus on how a preventative approach can be enacted.
The other new papers help in this respect. The first of these lays out a pilot project to identify preventative spending in the Scottish budget, a commitment made in the Public Service Reform Strategy last year. The pilot uses a tagging exercise to sort budgeted spend for 2025/26 into preventative, enabling, acute/responsive, and other/general service spending. The results classify about 15% of the analysed spend as preventative, breaking down into about 3% primary prevention and 6% each secondary and tertiary prevention. The accompanying preventative budget tool and prevention toolkit provide guidance to those carrying out similar exercises.
The results of the pilot are broken down by portfolio in the table below. Health and social care spending controlled by health boards dominates the exercise, representing about 80% of the spending analysed. Scottish Government-controlled spending brings health and social care to around 93% of the analysed spend.
| % of analysed budget tagged as… | |||||
|---|---|---|---|---|---|
| Portfolio | Budgeted spend analysed, £m (% of total analysed) | Total preventative | Primary prevention | Secondary prevention | Tertiary prevention |
| Health and Social Care (SG spend) |
2,586 (62%) |
20% | 4% | 9% | 6% |
| Health and Social Care (Health Boards) |
16,001 (100%) |
11% | 2% | 3% | 6% |
| Education and Skills |
607 (19%) |
61% | 5% | 50% | 6% |
| Justice and Home Affairs |
270 (8%) |
15% | 0% | 2% | 12% |
| Social Justice |
163 (2%) |
85% | 7% | 63% | 16% |
| Deputy First Minister, Economy and Gaelic |
166 (27%) |
54% | 1% | 49% | 5% |
| Rural Affairs, Land Reform and Islands |
96 (10%) |
31% | 31% | — | — |
| Net Zero and Energy |
143 (104%)* |
57% | 50% | 7% | — |
| Total |
20,032 (41%) |
15% | 3% | 6% | 6% |
Source: Scottish Government and FAI calculations
* This percent is over 100 because the total portfolio figure is based on net spend (expenditure minus income generated).
Level 4 budget lines are not as detailed as is demanded for this kind of analysis; to get the detail required, the prevention unit have gotten more information about how budget lines break down and assigned percentages of preventative versus other types of spend. The prime example of this is the parallel pilot conducted with health boards, where the Scottish Government team provided guidance and support to health boards to carry out a tagging exercise on their own budgets.
As one might expect, the share of preventative spend varies greatly over different portfolios, and is likely to be influenced significantly by which budget lines were included. The split between types of prevention is tipped towards secondary and tertiary prevention. The exceptions are the portfolios for Rural Affairs, Land Reform and Islands and for Net Zero and Energy, which presumably have high proportions of primary prevention spend because they cover things like natural resources, peatlands, and flood risk management. These categories of spend affect fundamental environmental factors and are not targeted at specific population groups.
The pilot also tags preventative spending for specific outcomes and drivers of service demand based on the stated goals of the spending. The idea here is that prevention can only be assessed in relation to what is being prevented – and that preventative budgeting likewise needs to define the outcomes or service demands that it is intending to prevent. The exercise tags for both the primary and secondary outcomes of spending. Childhood development concerns and poor health stand out as the two outcomes linked to the highest level of preventative spend, over £1b each. We found it interesting that, despite its centrality in government priorities, inequality and poverty came third, linked to around £600m and almost entirely as a secondary outcome.
A few caveats apply to the pilot. The pilot covers 99 lines in the Scottish budget at Level 4 (the most detailed available), representing about 41% of budgeted spend for 2025/26. Budget lines were included on the basis of availability of data and an attempt to get a spread across portfolios. The pilot exercise tips heavily towards health and social care, and did not cover categories like local government funding and most benefits. The inclusion of the latter categories could change the results considerably while also raising some interesting questions – something to look out for in later updates on both amount of preventative spend and linked outcomes and drivers of demand.
Another health warning provided in the paper and the accompanying tools is that tagging budget lines for prevention and outcomes is inherently a subjective process. This is particularly true when judging the level of prevention, or the line between tertiary prevention and acute spending. The accompanying toolkits provide some guidance on thinking here, but the exercise would undoubtedly come out a bit differently depending on who carried it out. For example, the Scottish Government guidance states that primary prevention tends to be population-wide, whereas targeting (associated with secondary or tertiary prevention) implies that problems are already apparent. This differs slightly from PHS’s definition, where primary prevention can be universal or targeted. This may or may not be true in all cases and is likely to be an area of debate.
This is clearly an intermediate step, and we welcome the transparency of showing the government’s work at this stage. The pilot paper sets out clear next steps – the exercise will be extended to the full 2025/26 budget later this year, and then carried out for the 2026/27 budget. This will include carrying out a similar exercise with local authorities as with the health board pilot to get detail on preventative spend within the local government budget allocation. They also intend at a later date to track outturn spend, which will help to see if planned preventative spending carries through to what is actually spent. And of course, even if money was spent on prevention, that does not mean it was necessarily effective – something the prevention unit also aims to collect evidence on in the future.
Crucially, the pilot is meant to establish what is currently spent on prevention – not to establish a process for incorporating prevention into the budgeting process. The latter is something we’d ideally like to see in the future, along with continued budget tagging like that presented in the pilot so that prevention spend can be tracked over time. As with any subjective exercise, we’re also keen that budget tagging is carried out to be useful in the budgeting process, not to provide self-congratulatory statistics to score political points. To that end, when the full budget is analysed, we’d welcome the publication of the results spreadsheet showing what has been tagged as preventative; this would allow others to scrutinise the results fully.
Hopefully, this blog has given a sense that there is a lot to look out for in the future on preventative budgeting. That includes our own work, which will explore potential recommendations for best practice on accounting for prevention in budget decisions. Later this year, we’ll publish more on this, including case studies on international and local examples. Stay tuned!
Authors
Hannah is a Fellow at the Fraser of Allander Institute. She specialises in applied social policy analysis with a focus on social security, poverty and inequality, labour supply, and immigration.
Spencer is a Senior Knowledge Exchange Fellow at the Fraser of Allander Institute.