Square peg, round hole: What’s needed to deliver prevention policy

Lucy Mulvagh shares how she used the Centre for Public Policy Practice Fellowship to examine prevention and its barriers to implementation

This article was first published by the University of Glasgow’s Centre for Public Policy

In June 2025, Scotland saw the publication of ambitious ‘new’ policy in the form of three major documents – on public service reform, population health, and health and social care service renewal.

Like the Christie Commission report issued nearly 15 years earlier, all place a strong emphasis on prevention. But how – this time – to avoid the well-kent ‘policy implementation gap’ and ensure its delivery as intended?

Because despite a widespread and shared intent, prevention remains stubbornly difficult to deliver in practice. We know what’s needed; the question is not what Scotland should do, but why the system struggles to do it.

This was the enquiry I set myself for the Centre for Public Policy Practice Fellowship; a golden opportunity to gain insight from great minds at the University of Glasgow. The timing felt particularly right to focus on prevention, by which I mean putting effort and resources into stopping negative outcomes from occurring, or intervening early to stop them becoming worse. At the ALLIANCE, we are particularly focused on the prevention of health inequalities; that is, the systemic, unfair – and entirely avoidable – differences in health across population groups.

Implementing ambitious prevention policy means doing things that some key public sector stakeholders find difficult for a range of cultural and practical reasons. I started by sense-checking six of these policy delivery actions:

• Embedding co-production as shared decision-making, not merely consulting.
• Aligning resource raising, budget allocation and spend with long-term preventative outcomes.
• Ensuring transparency of decision making, including on prevention spend and outcomes.
• Enabling and taking courageous leadership and managed risks.
• Using mixed evidence, including from the third sector and rich qualitative lived experience data, to support decision making.
• Collaborating across organisational and fiscal siloes.

Through the Fellowship, I was extremely fortunate to be connected with three eminent scholars: Professor Sara Macdonald, Professor Adina Dudau, and Dr Claire MacRae. I had fascinating and insightful conversations with each; they all kindly shared their expert knowledge, and pointed me in the direction of other sources. Adina in particular gave me lots of her time and even tailored briefings.

Interim conclusions

Given the daily pressures of work – something that others in the third sector will readily recognise – I am still working my way through all this rich data from my engagements with researchers. However, I have come to some ‘interim’ conclusions.

Firstly, too many elements of the current implementation system present barriers that don’t just block successful delivery of prevention policy, they actively work against it.

This includes:

• Structural barriers:
  • late-stage consultation
  • short-term budget, pilot and evaluation cycles
  • siloed delivery, governance and accountability structures
  • fiscal misalignment
• Cultural barriers:
  • risk aversion and avoidance
  • power protection
  • organisational defensiveness
• Political barriers:
  • working to electoral cycles
  • opaque decision making
  • fear of blame
• Technical barriers:
  • narrow evidence standards
  • fragmented data
  • third sector capacity constraints

Taken together, these point to an uncomfortable truth. Scotland’s public sector continues to operate within systems that are designed for – and incentivise – control, certainty, silos, and short-term accountability. This is at odds with simultaneously asking it to cede power, take a joined-up approach, and meaningfully collaborate with the third sector and communities to deliver long-term change.

Prevention will not fail because the vision is wrong or the intent is not there. Wholescale system change is an imperative, but we keep footering around the edges and trying to shove a square peg into a round hole. The implementation system is not fit for purpose; intentional, targeted action is needed to tear the barriers down and make prevention the easiest thing to do.

There are several people I’d like to thank.

I am very grateful to Theresa Shearer, for proposing me to the Fellowship programme, and to Sara Redmond, the ALLIANCE’s Chief Officer-Development, for her encouragement.

I’m indebted to Professor Sara Macdonald, Professor Adina Dudau, and Dr Claire MacRae for their time and expertise. Also to Dr Sarah Weakley and Lynda Frazer at the Centre for Public Policy for all their help and advice.

Finally, at the same time as the Fellowship I was fortunate to work with third sector colleagues on a joint statement on prevention. This involved much thought-provoking discussion, and I owe thanks to Sarah Boath, Andrew Paterson and Sam Jordan at SCDC, Sarah Latto at VHS, and Stephanie-Anne Harris at the ECHF.

End of page.