2040: A Health Odyssey
FEATURE - 20TH DECEMBER 2016
Over the coming decades, the health of the UK public is likely to be buffeted by a huge number of economic, social, technological and demographic changes. A landmark study from the Academy of Medical Sciences has set out to explore how new approaches to research could help ensure that when 2040 rolls around, ours is a far healthier population than current trajectories might suggest
“I would not want to be without a really good doctor when I’m sick,” says Professor Dame Anne Johnson, one of the country’s foremost epidemiologists, expressing an opinion that all of us, however insignificant our academic credentials, could doubtless assert with similar confidence. “But isn’t it great if most of us, most of the time, can stay out of that doctor’s surgery because the environment is right for us to live a healthy life?”
On one level, this is a statement of the obvious: the truth about doctors is that however deep their knowledge, however reassuring their bedside manner, however sophisticated the technology at their fingertips, our aspiration ought to be to have as little to do with them as is humanly possible. But once you start digging
a little, it is remarkable the extent to which our entire health service—together with the research that supports it, and the political structures that determine its priorities—is geared towards treating sickness rather than promoting health.
For the past few years, Professor Johnson has been leading a working group at the Academy of Medical Sciences investigating how, through a reorganisation of the medical research environment, the future might be shaped so that 25 years from now as many as people as possible are keeping out of doctors’ surgeries, hospital wards and nursing homes—and certainly more people than we might expect based on current trajectories. The resulting paper, entitled Improving the Health of the Public by 2040 was published by the academy in September 2016.
74.3 MILLION. If current trends continue, the UK population in 2039 will be 74.3 million
From its title alone, you might expect the report to boil down to list of personal rebukes: eat less rubbish, run more, stub that ciggie out. But its conclusions are far more detailed and nuanced than that. “This project isn’t simply about what people call ‘lifestyle choices’—for a start, a lot of lifestyle things aren’t choices,” explains Professor Johnson. “It goes far beyond whether or not we’re worried about how many steps we’ve taken today, or how well we’re eating. For a lot of people, it would be a privilege to even consider such things, and there are so many other drivers that influence our health: our education, our income, the work we do, the cities we live in, the air we breathe. When we think about how we might improve the health of the public over the next 25 years, we need to bring that broad perspective into research.”
It was with this broad perspective in mind that the team decided that new terminology would be required to define the study’s focus. “Rather than referring to public health, we’ve used the term ‘health of the public’,” Professor Johnson explains. “You might think this is splitting hairs, but when people think about specialists in public health, of which I am one, they think of quite a narrow group of doctors and other professionals who might be concerned with immunisation programmes, for example, or clean air or anti-smoking interventions. We’re trying to say that if you really think about things that make for a healthy public, they go far, far beyond biomedical science, and they go far beyond the professional discipline of public health.” The health of the public, she says, is affected by a hugely diverse range of disciplines that wouldn’t usually be considered part of the public health field, from natural and social sciences to urban planning and the arts.
The 25-year scope of the study is not, she says, “a magic number”, but one that helps to emphasise the long trajectory of what determines our health. “For example, we know from research done by population scientists and epidemiologists that the kids today in our schools who are obese—and a significant fraction of children are leaving school overweight or obese—are already stacking their risks going into the future, in terms of diabetes, heart disease, cancer and so on. Those kids now, they may be 15, 16, but they’re going to start getting really sick within 25 years. If you want to think about that long-term trajectory, we have to intervene now.”
5.2 MILLION. By 2037, the number of city dwellers in the UK is set to grow by 5.2 million
The pattern of the past few decades suggests that while people are living longer, the measure known as ‘healthy life expectancy’ (essentially, how many years a person will spend in either ‘very good’ or ‘good’ health) is not increasing at anything like the same pace: a trend that, if it continues over the coming decades, will have a huge impact on both the quality of life of the public and the finances of the nation. Living past 100 is all very well, but it isn’t much fun for anyone if you’re still battling multiple morbidities from the age of 65. “We want to see people being able to live longer, healthier lives,” says Professor Johnson. “Our aim should be to increase healthy life expectancy, not just life expectancy.”There are many factors that will determine how healthy the British public will be in 25 years: the impact of climate change; the growth of cities and shifts in their demographics; the benefits and threats of emerging technologies, together with the staggering level of data capture that they enable; the changing nature of work, with greater automation and less job security; behavioural factors such as alcohol consumption, diet, smoking and physical activity; global patterns of antimicrobial resistance and pandemic disease; and changes to the health and social care environment, with increased levels of technological and biomedical innovation making treatments increasingly effective, but a seemingly unbridgeable shortfall in funding putting the timely and equitable provision of these treatments at risk.
Among these complex and occasionally elusive inputs, there is one clear and unequivocal trend that is bound to have a huge impact on shaping the nation 25 years hence: increased life expectancy. “We will probably continue to improve our life expectancy, overall. We know that in 25 years we’re going to have a much higher proportion of older people, and it’s when you’re older that you put the biggest strain on the health service,” Professor Johnson explains. Current projections for what the UK population will look like in 25 years suggest that the size of the working-age population will be broadly similar to that of today, while older generations will be disproportionately large. The number of people aged 75 and over is projected to rise by 89.3%, to 9.9 million in mid-2039, the number of those aged 85 and over will more than double, and the number of centenarians will rise nearly six-fold.
38%. By 2025, the UK is predicted to have the highest obesity rates in Europe, at 38%
Another vital ambition, she insists, should be the reduction of inequalities in health, which are currently stark. Across the population, the correlation between low incomes and ill-health is striking. “There are huge differences in life expectancy depending on where you live and how high your income is. If you live in the poorest parts of Glasgow, you’re likely to live many years less than if you live in a rich part of Glasgow. Absolutely the same in London: living in central London you have a very high life expectancy, but if you look at the more deprived parts of east London, it declines dramatically. While we’re living longer, we’re not reducing that gap.”
So how do you go about shaping a nation that remains healthy as its ages; becomes less demanding of expensive clinical interventions and long term social care; with less of a disparity between the health of the rich and the health of the poor? Professor Johnson doesn’t claim to have the answers, but what she and her colleagues have concluded is that far greater investment in prevention research is required if meaningful solutions are to be identified. We need, she says, to develop a better understanding of the wider determinants of health—be they social, cultural, environmental or behavioural—and a more acute sense of how population-level interventions could make the public healthier. “If you look at the amount of money spent on prevention research in the health sciences, it’s currently only about 5% of the total,” says Professor Johnson. “We must invest more in public health, we must invest more in prevention.”
She uses the example of cardiovascular disease to underpin her point. Since 1969, the age-adjusted mortality rate for cardiovascular disease—which includes heart disease, heart attacks and strokes—has fallen by 74%: an extraordinary improvement in a relatively short period of time. A large part of this seismic shift has come about through improved biomedical understanding: more effective blood pressure control, for example, or better treatment of heart attacks. But non-clinical factors—changes in diet, a reduction in smoking—have played an equal part. They just haven’t been so nearly well understood.
This, says Professor Johnson, clearly illustrates why broader prevention research and the driving of a prevention agenda into clinical practice could be so telling. “If you ask the average doctor what the cause of a patient’s heart attack was, they’ll likely say something like: ‘a clot in an artery.’ But that isn’t the full story. If a person lives in a poorer area, they’re much less likely to have access to the best medical services, so are less likely to have had their blood pressure read or controlled. Then you look back at their lives, and they’re more likely to have smoked, been exposed to air pollution, worked in a stressful job in a poor work environment, been brought up with a poor diet, had less education. Some of these social things are in a sense the cause of the cause. We have to put these things together. If I have a heart attack, I jolly well want the best possible surgery to fix it, but along the line I could have got away with not having a heart attack in the first place.”
The report suggests that as well as requiring more substantial funding, prevention research would benefit from a shift in emphasis, from observational to interventional—or, to put it another way, solving problems rather than simply describing them. Efforts should be focussed on interventions that can be applied to populations, systems and organisations, rather than those that focus on individuals. And evaluation of these interventions needs to be of the highest quality, offering a proper assessment of both efficacy and cost-effectiveness.
All of this demands a more strategic approach to health of the public research, rather than the somewhat diffuse system currently in place: a complex web of funders and researchers with very little central coordination. To these ends, the report recommends the creation of a new agency known as the UK Strategic Coordinating Body for Health of the Public Research, made up of representatives from public and charitable research backers and relevant government departments, whose role it would be to identify and prioritise research initiatives.
When undertaking prevention research in the coming decades, the opportunities offered by the ongoing digital revolution are vast. In a process that is proving both cumbersome and eye-wateringly costly, our medical records are gradually being digitised, meaning that opportunities for interrogating large medical datasets should expand significantly. Quite how and to whom those records might be made available is a matter of some debate, but Professor Johnson is convinced that creating a system in which medical data can be used
for valuable research without breaching patient privacy ought not to be a complex task. “Arguably, they can be rather better protected in electronic form that they are when they’re being wheeled around on a trolley in a hospital—as long as we get the governance right,” she says.
Even greater potential—and significantly greater sensitivity—could be unlocked if this medical information were to be matched with the vast quantities of data collected by private companies every time you switch on your smartphone, browse the internet or pay for your weekly shop, the synthesis of which could have a profound impact upon our understanding of the health of the public. “Think about supermarket loyalty cards—they have so much information about what people eat and drink and how much they spend, which is extremely informative for all sorts of commercial purposes but would also be very informative for health,” says Professor Johnson. This would require that a consensus be reached over the knotty commercial and ethical implications of using private data. “Companies like Google know where you are and what you are doing almost all the time. Do most people know that? Do they mind? I think we need to start having a dialogue with the public about data and how we can use it to benefit people’s health.”
Further ethical conundrums will reveal themselves when policies designed to improve the health of the public cut across people’s personal and commercial freedoms. “We have to think about the ethics of human liberty: these are big debates and there are all sorts of competing interests,” says Professor Johnson. “But whatever we do, the starting point for health of the public research is understanding how those various levers you can use will alter human behaviours. How you use them and how much you invest in them are ultimately political decisions.”
Approximately 91% of baby boys in East Dorset are currently expected to reach their 65th birthday. The same figure for Glasgow City is just 75%
These political decisions should, she says, span just about every area of public policy and be driven by long term health outcomes rather than balance sheets. “How do you achieve those things in a society where mostly we value things around immediate economic outcomes? We need a better understanding of the impacts of fiscal policy—fiscal policy might be measured largely on whether the country gets richer, but you also have to take into account what the impact of that policy is on health, which might make the economics look very different.” For example, if a policy designed to reduce government spending also happens to have a negative impact on the health of the public, the costs associated with supporting a less healthy population would render that initial saving a false economy. “That means you have to engage across government on issues of health; you won’t reduce health inequalities unless you reduce the drivers that create them.” The report proposes that health of the public experts should be embedded in every government department.
The report also highlights the need for public health and clinical practice to become more closely aligned, with doctors trained to better understand prevention, population data and competing risk. Moves are already afoot to make this happen. “You never quite know how these things will land, but there are discussions already underway about reframing academic career pathways. I’m in talks with a number of medical schools and the Medical Schools Council about developing curricula. Very often, you’re not trying to invent this from square one: you’re trying to bring forward good practice. Edinburgh is currently teaching everybody medical informatics, for example, and teaching them much more about data science as they go through medical school. We’ll also work with some of the royal colleges on the potential for teaching doctors some of these skills after they’ve qualified.”
Attempting to make Britain a healthier place in 2040 than current projections would suggest is going to be a significant undertaking. But there is no time for delay. The future, when it comes to improving health, starts today.
WHAT IS THE ACADEMY OF MEDICAL SCIENCES?
The academy, based on Portland Place, is an elected fellowship of medical researchers. It has over 1,200 fellows, about half of whom are clinically qualified, the other half being laboratory scientists in a range of disciplines. It is not a major funding agency; it instead seeks to promote excellence in research, influence policy to improve health, promote careers in medical research, and foster links between academia, industry and government. Its reports tend to review a specific topic related to biomedical science, identify where the gaps are in the research environment, and make practical recommendations for how progress might be made. Funding comes from a combination of subscriptions, donations and government grants to support the academy’s work.