Learning from 25 years of preventative interventions in Scotland

4. Case Study Selection

4.1 Selection process

Case studies were selected for inclusion where there was good quality evidence of impact in Scotland. ^[3] Case studies with particular relevance for public service reform were also prioritised for inclusion. This included case studies which involved system change, were cost-effective and potentially scalable.

The selection process began with a longlist of nearly 50 relevant case studies complied following discussion with Scottish Government analysts, a review of the literature and engagement with organisations including Public Health Scotland and the Improvement Service. Following a review of the evidence and discussions with analysts, the long list was distilled down to 15 case studies.

The final selection of case studies includes a breadth of different preventative approaches drawing on examples of primary, secondary and tertiary prevention and including examples from across a range of policy areas. For each case study, policy and analytical leads in the area were consulted to better understand the policy context and provide available evidence.

4.2 Case studies not included

The aim of this work was to highlight examples of successful preventative interventions. Therefore this report does not consider examples of preventative interventions that were ineffective, as this was out with the remit of the work.

There were some potentially good examples of preventative interventions which were not included in this study because:

i. there was a lack of robust evaluation evidence from Scotland demonstrating impact

ii. the evaluation was at an early stage and on-going (e.g. Young Persons’ Free Bus Travel Scheme)

iii. the intervention was not unique to (or delivered in a distinctive way) in Scotland and had not been fully evaluated in Scotland (e.g. Bowel and Cervical Screening)

iv. the intervention was too similar to other programmes included as case studies (e.g. the Human Papillomavirus immunisation programme at age 12-13 in Scotland provided a highly effective example of prevention but the Covid-19 vaccination case study already provided an example of a vaccination programme).

There are some exceptions to this, where case studies have been included despite not meeting all of the criteria above. This was either because the intervention was of particular interest to learning around public service reform (e.g. Breastfeeding Friendly North Lanarkshire – BFNL - which is not an impact evaluation), or because examples of impact in that policy area are hard to find, but the intervention was evidence-informed and showed some evidence of impact (e.g. see case study on the Caledonian System).

4.3 Observations on the range of case studies identified

4.3.1 Intervention types

The interventions included a mix of national programmes/ large scale programmes (e.g. Covid-19 Vaccines, FNP, the NNP and HFP) and policies (e.g. Smoking ban in Scotland, MUP, SCP), as well as smaller scale local projects (e.g. Access to Welfare Advice in Schools in Edinburgh and BFNL). The case studies included several examples of interventions that started from local pilot studies within a small number of local authorities / health boards but were then successfully scaled up to national level interventions as a result of positive evaluation evidence.

Both ‘upstream’ and ‘downstream’ interventions are included. The former focus on the root causes of a problem before it manifests (e.g. FNP, Access to Welfare in Schools), whereas ‘downstream’ interventions manage the consequences of problems once they have occurred (e.g. the Caledonian System, the NNP). These broadly correspond to prevention levels (Figure 2), but in reality this is more nuanced, and arguably some of the interventions could have been considered to cover more than one level of prevention (for example the case study on Housing First).

There is an established literature that outlines the additional benefits of primary prevention and early intervention in the pre-birth period and the early years of life. Investing in preventing negative outcomes for children and young people, means that the positive benefits of prevention activity have the potential to be realised across the life course and can impact on subsequent generations. In other words, the “return on investment” is typically higher for primary prevention in the early years of life.

The vast majority of the case studies (11 out of 15) are examples of primary prevention. One third of the case studies were focussed early in the life course and directly aimed at pregnant women, babies and/ or young children: Financial Incentives for Smoking Cessation in Pregnancy^[4], FNP, Breastfeeding Friendly North Lanarkshire, Childsmile and the Scottish Child Payment.

However, while return on investment may be lower for older age groups, there is still a positive return on investment, in many instances, to be had from investing in prevention further up the age range. Examples of secondary prevention (FSS and financial incentives for smoking cessation in pregnancy) and of tertiary prevention (NNP and the Caledonian System) are included as there will be an ongoing need for effective secondary and tertiary preventative interventions.

Source: Institute for Government analysis

4.3.2 Timing and duration of interventions

The case studies highlight examples of effective preventative interventions in the period since Scottish devolution. The earliest example is smokefree legislation (2005), followed by financial incentives for smoking cessation in pregnancy (from 2007), the Caledonian System (2011) and NNP (2011).

A number of the interventions were affected by the Covid-19 pandemic and had to adapt over this time, and in several cases this also affected the evaluation. The majority of the case studies cover ongoing interventions, although in many cases the programme or delivery model has evolved over time.

4.3.3 Policy areas

Over half of the case studies relate to public health interventions, which in part reflects the stronger culture of research and evaluation that exists within health. Several more of the case studies sought to address health outcomes, such as road accident deaths/injuries or mental and physical wellbeing outcomes among long-term homeless.

The remaining case studies were drawn from; transport; early years; crime and justice; employability; housing; and social security. As might be expected, several of these cut across multiple policy areas, such as transport and health (20 mph limits, Safeguarding Vulnerable Road Users) and housing and justice (HFP).

This work did not aim to be comprehensive and there are some notable gaps in the cases studies selected. For example none of the case studies consider prevention in the policy areas of the environment or education (although the Access to Welfare in Schools case study is about an intervention situated within schools).

4.3.4 Innovative approaches to prevention in Scotland

There are several examples of where Scotland has developed new and innovative approaches to prevention. For example:

• In 2005 Scotland was the first part of the UK to introduce legislation to make it a legal right to breastfeed in any public place where children are allowed.
• In 2006 Scotland was also the first UK nation to bring in legislation to ban smoking in enclosed public spaces.
• In 2011 the Scottish Government implemented the world’s first NNP, providing take-home naloxone kits to people who use drugs likely to witness an overdose.
• In 2018 Scotland became the first country in the world to implement its model of a minimum unit price for alcohol, with the World Health Organisation recommending that other countries learn from Scotland’s approach.
• In 2021, the Scottish Government introduced the SCP. The SCP has been described by Professor Danny Dorling as the single policy intervention that has created the largest fall in child poverty anywhere in Europe for at least 40 years.^[5]
• Safeguarding Vulnerable Road Users is another innovative approach to casualty reduction that sets out to ‘prime’ rider behaviour by developing unique road markings for motorcyclists which prevent them being killed or seriously injured.
• The Scottish Childsmile approach has been internationally recognised, being awarded a certificate of best practice by the European Commission in 2019.