One of the struggles facing policymakers who advocate prioritised spending on prevention is that they are rarely able to take credit for the accrued success of their initiatives. Savings are usually realised in different parts of the system from where the original preventative measures were invested, or they happen over timescales that stretch beyond the policymakers’ involvement. There is an obvious appeal of investment in a public service (indeed, any investment) that yields an immediate and visible return.
Understanding ‘what works’ in regards to social interventions is a complex venture. In addition to questions about evaluation quality, the understanding must always dig deeper into the when, for who, and where. A miscalculation on any of these three W’s can undermine even the strongest evidence-based intervention as was discovered with what was widely considered to be one of the most prominent evidence-based programmes, the Family Nurse Partnership (FNP). FNP’s evidence base was incredibly strong in the US, yet after millions were invested in importing and scaling the intervention across the UK it was found to be ineffective in relation to its intended outcomes, which included the rate of smoking during late pregnancy, the child’s birthweight, the occurrence of a second pregnancy within 24 months, and the number of emergency room and hospital visits for the child within 24 months.
Addressing and preventing the various forms of child abuse, neglect, and exploitation is a unique challenge in and of itself. In part, this is due to the sensitivity and difficulty in evaluating programmes that serve such a vulnerable population, and that some of the effects of child abuse are not apparent until much later in life.
It is important to fully understand and research the potential for an intervention to address the diverse ways by which harm manifests. For example, how might intervention x address the immediate shame and anxiety a child might experience? When is the best time to intervene with y to ensure that late onset depression is stemmed?
This appreciation of complexity and need requires ‘thinking like a system’, but it is only part of the roadmap for effective change.
Acting entrepreneurially, with a goal of activating effective investments to prevent harm, makes up the second part of a roadmap for policymakers. Outcomes emerge in the short, medium, and long term as people’s lives unfold. The sequence of outcomes longitudinally is important. It is often the end-of-sequence outcomes that hold the most significant economic implications, and where the (economic) case for investing in prevention, upstream becomes apparent. There are established causal links between child abuse and long-term outcomes including fewer years in education, increased criminal behaviour, and adult onset increases in BMI, phobias, major depression, and substance dependence.
The greatest costs of abuse are of course experienced by victims themselves. A recent Public Health England report sensitively highlights the emotional cost to the individual and the wider socio-economic costs to society as a whole. It attempts to quantify the benefits of investing in prevention. For instance, take the ‘Homebuilders’ intervention exemplified in the report, which provides counselling and education to families with a child at immediate risk of being taken into care. After accounting for the intervention cost and its subsequent effects in education, health, earnings, and avoiding an out-of-home placement, the intervention presents a £7,900 cost-benefit per family that receives it. This is calculated as the benefit to the individual, the taxpayer and others, less the cost of the intervention. Other child maltreatment-focussed interventions such as ‘Parent Child Interaction Therapy’ and ‘Alternative Response’ see cost-benefits up to £2,900 per family.
These are great starting points for entrepreneurial responses - taking ideas and insights and adapting them for the local context. Recent work by the RSA has shown how problems are not markets and that the assumption that good ideas will scale simply because they are good ideas is false. Often, the failure is to recognise that context matters – the building blocks of success in one locality may simply not exist in another. The entrepreneurial response is to be creative and adaptive in establishing those foundations. The earlier example of the family nurse visiting programme (FNP) would have had legitimate claim to a £7k cost-benefit per family using the same calculations employed above. However, its evidence base was almost exclusively developed in the US, where health visiting during pregnancy (a core tenet of the intervention) is not a common concept.
The complexity surrounding how a programme establishes its evidence base underscores the need to ‘think like a system’ – a more nuanced approach to ‘what works’, particularly around the ‘where’ may have led to a smaller pilot through a randomised controlled trial of FNP rather than a premature country-wide scaling. To their credit, the consortium responsible for FNP are now reflecting on the adaptations required to make the programme more effective in the UK, but it remains a useful illustration of the consequences of miscalculation in prior thinking about ‘what works’. We need to be more considered in scrutinising the evidence for ‘what works’, because context matters hugely.
Overlooking that context is indicative of the linear fallacy that if only the problem can be defined and a solution designed, all that remains to be done is to successfully implement it. Of course, we know this is not what happens in reality. Not only has the service user not been involved, but often by the time the implementation starts, the world has moved on, the context has changed. As a result, the initiative will fail to meet the needs of the individual and community, an example of the type of behaviour that makes systems change such a challenge. As my colleague, Ian Burbidge, noted in his analysis of ‘energy for change’, the response to a complex problem must align the needs of the hierarchy, community, and individual if it is to make for an effective intervention.
Making the case for investment in prevention is notoriously hard. That is in part because the pathways that link interventions to outcomes run through the existing landscape of public services and unpredictable life courses. To those designing and commissioning services, navigating this complexity requires systems thinking, and the entrepreneurialism to respond intelligently to context.
Disclosure - Luke Timmons is one of the authors of Public Health England's "Rapid Review on Safeguarding to Inform the Healthy Child Programme 5-19" and previously worked for the parent company of Dartington Service Design Lab, a member of the consortium who leads the Family Nurse Partnership National Unit.