The power of prevention

The Victorians pioneered the pre-emptive approach to social ills. Their visionary reforms could teach our government a lot, says David Robinson
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Indy Lifestyle Online

The drums had been rumbling for 20 years or more but it was in the 1860s that the British revolution really began. The first public health act in 1848 followed years of campaigning and was, in its day, visionary and ambitious – but its implementation was flawed and patchy. Progress over the following 15 years was piecemeal, at best, and it wasn't until the flowering of the local boards of health throughout the 1860s, the 1866 Public Health Act and the Royal Sanitary Commission in 1869 that a smattering of isolated reforms became an unstoppable force transforming sewage disposal, water supply, rules for burial and food inspection, regulation of buildings and public places.

Collectivism – large-scale, consistently administered state services designed best to ensure the health and safety of the citizen – had begun, and it was a breakthrough vision not primarily about pipes and sewers and tedious regulation – these were just the means of achieving it – but about good health and the insight that this was a proper concern for government. That effective public provision could prevent disease, accidents and premature death.

A century and a half later, prevention and a commitment to sustaining good health sit alongside acute provision for those in need as complementary functions of government. Even in the current debate about health-service reform no one argues that this is not essentially the right thing to do; a shared responsibility in pursuit of a common goal.

Just as we can see that the health of the nation isn't shaped only by emergency surgery, we must also recognise, for example, that a safer and stronger community isn't dependent only on more police and secure prisons – essentially last-resort services, the equivalent of the triple-bypass operation, a drastic and, in every sense, expensive response to desperate circumstances. Open-access children's play schemes, after-school clubs, youth groups and detached work are cheaper, more likely to secure the long-term well-being of the child, and far more likely to prevent a repeat of the recent riots than stiff sentencing.

The Rokeby Community Links Hub, a small neighbourhood centre in Stratford in London running these kinds of activities, opened in 2009. A year later, the police were attributing to the Hub a 56 per cent drop in reported crime on the local estate – from 477 incidents down to 211. Other residents felt safer, went out more, mixed with their neighbours more. Unsurprisingly, within 12 months 80 per cent felt that the area had changed for the better.

"Public well-being", which the Prime Minister has recently committed to measuring, is not nurtured by late and desperate intervention, just as open-heart surgery contributes little to public health. This may be common sense but, as I see in my work as a community worker, it isn't common practice. Some 150 years on, the prevention revolution is unfinished.

Moral commitment powered the Victorians, but it wasn't the only driver. Unyielding campaigners such as Lord Shaftesbury were strengthened by their faith but also armed with some extraordinary statistics. The scientist and Liberal politician Lyon Playfair, for example, found, as early as 1841, that of the 102,025 Lancastrians who died that year, 83,616 were under 20 – and that 14,000 of those deaths, and a further 398,000 cases of illness, had been preventable. With awesome precision, he calculated that the financial cost to the county was £5,133,557. Similar work was undertaken in cities and counties across the country. This was the economic case and it informed not only the moral argument but also the political one: the commercial classes paid their rates and still suffered from absenteeism, from sustained illness, the premature death of experienced workers and, worst of all, from the rampages of epidemics that, like burning streets, respected neither class nor income. If these things could be prevented it was government's job to do it.

The principles of this argument for tackling the causes of cholera or typhoid might be similarly applied to, for instance, the costs of youth crime or underachievement at school now borne by individual businesses, households and communities and, collectively, by local taxpayers and the national exchequer. Tackling these problems early is intelligent government and good business. Playfair would have enjoyed Professor James Heckman's recent public lecture at the LSE, where he observed that the Vancouver-based Parent Participation Programme has enjoyed higher rates of economic return over the past 50 years than equity markets.

A report commissioned by Catch22, a youth charity supporting 10- to 25-year-olds, through the New Economics Foundation, an independent think tank that aims to improve quality of life by challenging mainstream thinking on economic, environment and social issues, found that adopting a more joined-up approach to services for young people would see a return of £5.65 for every £1 invested. Youth unemployment currently costs £8bn a year, and youth crime £1bn.

Similarly KPMG has calculated that the failure to learn how to read in primary school has a lifetime cost to the state of between £45,000 and £55,000 per child. A reading-recovery programme costs £2,600, has a 79 per cent success rate and yields a return of between £11 and £17 for every pound invested.

Wherever you look, the story is the same: youth unemployment; debt; antisocial behaviour; bullying; underachievement at school, particularly in the basic skills; family breakdown; drug abuse; homelessness; violence in the home or on the street – all the contributing factors to disorder on the streets – cost more when tackled later. And that's at best. Sometimes, later is too late for any intervention ever to be totally successful.

Officials from the Department for Communities and Local Government have been required to ask of every initiative: "How does this promote localism?" and "How does this give power to citizens?" Suppose policy-makers in every government department and in every delivery agency locally and nationally were now empowered with a similar mantra and expected to ask of every service: "Is this at the right time?" And, if not: "How might we next engage one step sooner?"

Three reasons are most often cited for why this isn't happening already: lack of funding for prevention or earlier action, in the past, has constrained development; lack of development has restricted the range of tested programmes; and lack of evidence has discouraged funding. One explanation compounds another. But although it was ever thus, none of this stopped the Victorians – and look what they achieved. Breaking the impasse again with broader thinking, deeper investment and wider action on prevention matters now more than ever.

As the dust settles on local expenditure cuts, and work on reconfiguring services gathers momentum, we may be starting a cycle of diminishing support for early action, increasing the need for acute services. By summer 2012, we could be hurtling backwards. Alternatively, change creates opportunity – and imaginatively reconfigured provision could switch the direction.

A swift and radical switch of resources from acute services to community building and preventive action is impractical but a steady, incremental migration could be achieved.

The Government's stepped approach to the reduction of carbon emissions with Low Carbon Transition Plans is not dissimilar. Absolute proportions will vary from service to service but if the aspiration is gradually to shift the balance, government departments and local authorities might consider establishing and publishing Early Action Milestones, visibly charting progress on Early Action Scorecards. They could commit, for example, to spending 5 per cent of their budget on prevention and early action, aiming to increase that proportion by 5 per cent each year for the next three years.

Commissioners, charitable trusts, the Big Lottery, the new Big Society Bank, could provide incentive and sustain the transition in the third sector with similar milestones. And, of course, if we expect open and ambitious milestones from the funders, we should expect them also of the funded – the organisations delivering the services from community groups to council departments. Publicising and promoting this good practice would frame it as the expected behaviour of a progressive, forward-thinking organisation.

Early Action Transition Plans would face many challenges: public accounting procedures, commissioner priorities, funding constraints, problems with measurement – attrition, dead weight and attribution – would all obstruct progress. For this reason my organisation, Community Links, is bringing new energy and cross-sector thinking to the mission, and we have established the Early Action Task Force to examine these issues and to lead the charge, bringing together experts and practitioners around an 18-month programme. We are launching a set of ideas and initiatives in October.

The systemic barriers are formidable, but the bigger challenge is one of aspiration and ambition. We see hundreds of mostly small-scale initiatives achieving good results, equivalent perhaps to the scattered developments on public health in the 1840s and 1850s. Time now for the next revolution, for the bold vision of those pioneering Victorians, for scale and for national leadership. The Task Force won't deliver all the answers but I hope we will, to borrow Emily Dickinson's tingling phrase, "ignite the imagination and light the slow fuse of the possible".

David Robinson is senior adviser at Community Links and chairs the Early Action Task Force. Email him with any ideas for its launch in October, at: david.robinson@community-links.org

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