Downstream Drift: What if ‘health’ is part of the problem?
We opened the 2026–2027 Big Picture Thinking Seminar Series with Dr Ally Brown from the University of Strathclyde, sharing the ideas from his forthcoming book Downstream Drift: How Health Hinders Preventive Policy.
The book is being written right now — Ally is only a few weeks away from submitting his first draft — and he brought his work-in-progress to us for “its world premiere.”
Ally shared the argument, invited us to help him sharpen it, and asked for our reflections to inform the final chapter of the book. It was generous, honest, and quietly provocative.
The problem with prevention
Ally postulated that every government of the last twenty years has promised to move upstream. Gordon Brown, the Christie Commission, successive Conservative and Labour manifestos, the new Scottish Prevention Unit announced only last week — all committed to prevention. Yet we remain stuck in a reactive, downstream system. Why?
Ally set out three familiar reasons: the ambiguity of what prevention actually means; political short-termism; the difficulty of proving prevention works when success is invisible; and the challenge of coordinating action across siloed departments.
Then he offered another explanation — one that cuts across all the other explanations. The word “health” itself, he argued, might be part of the problem.
What health carries in its baggage
Words carry ideas with them. And “health,” Ally suggested, carries a specific set of assumptions from the medical model: that health is individual, that it lives under the skin, that ill-health has a specific biological cause, and that solutions belong to healthcare professionals.
This is not wrong. The medical model is powerful and necessary. But when we want to prevent ill-health at a population scale, we also need to look to the social model of health — the one Dahlgren and Whitehead sketched in 1991, where health is created in the conditions where we grow, live, work and play.
The trouble is that the word “health” tends to smuggle the medical model into every conversation, including conversations about prevention. Ally called this process downstream drift: the tendency for preventive policy, framed in the language of health, to end up as reactive, individual, medical work.
Six ways the drift happens
Ally identified six specific mechanisms through which this drift occurs in policy — each one named after a quote from the policymakers he interviewed across the Scottish Government and Greater Manchester Combined Authority during his PHD. A few stood out in the discussion.
“It’s health’s business to fix.” When social problems get called “health inequalities,” they get sent to health departments to solve. But health departments cannot act on poverty, housing, or early years experiences.
“Which two nurses do you sack?” Framing prevention as a health issue puts it in a false and unwinnable contest with the NHS. Money for early intervention gets pitched against nurses’ pay, or against people on waiting lists. But there is no reason preventive investment must come from the NHS budget — most social policy spending is already preventive of ill-health. The framing itself creates the false choice.
“It’s the thing you go to the doctor with.” When health means individual illness, we build our targets around specific diseases: cardiovascular disease, cancer, respiratory disease. That drags solutions downstream into clinical territory — screening, medication, cessation programmes — and away from the social conditions in which those diseases arise.
“That’s not health, that’s just a number that you have.” Health policy tends to demand a particular kind of evidence, drawn from evidence-based medicine — randomised controlled trials, systematic reviews, meta-analyses. These methods are excellent for enclosed biological systems. They are much harder to apply to messy social systems. So social policy that would benefit population health struggles to meet the evidence bar that health policy demands.
The other two mechanisms — that health policy can feel like “Fortress Health” from the outside, and that lifestyle approaches to prevention responsibilise individuals rather than changing their conditions — completed the picture.
What happens next
Ally has one more chapter of his book to write: what can we do about downstream drift? Ally acknowledged this is the hardest part. You cannot wave a magic wand to stop policymakers using the word “health,” or transform its meaning overnight. But there may be things we can do to limit or avoid these medicalising mechanisms — different terminology in some contexts, structural changes to how prevention is located in government, different framings for social inequalities in health.
The breakout rooms and the wider discussion generated a lot for Ally to take back to his manuscript, and he was warm in his thanks. The book will be published in paperback by Policy Press in November 2027.
From Ally
“Thanks so much to everyone who attended. I’ve been working on this a long time and it was great to premiere it with such a knowledgeable and thoughtful audience. I will now go back to the recording and my notes and add a few new things to my planning of the final chapter.
The book will be Open Access for those with institutional access, but I can send the PDF in full if you don’t. Please email me if you’d like a discounted copy, or if you have any further comments, reflections, or suggestions for who I should speak to. I’ll see some of you in the audience at future Big Picture Thinking seminars.”
Ally can be reached at [email protected].
Next up
The next Big Picture Thinking Seminar is on Thursday 22 October 2026 at 10am, when Diarmaid Lawlor of Scottish Futures Trust will speak on collaborative approaches to place, and what it takes to make better places to live well locally. Register on Eventbrite.