Health Futures

The NIHR asked for input for the Health Futures exercise, thinking about health and health care in the next 20 years.

The full report is available

Below are the thoughts submitted by the HSR Speciality Group

1) In relation to your area of interest (discipline or geography), what differences do you foresee in the state of health and provision of healthcare in England in 20-30 years’ time? In your answer, please consider if/how these changes might affect some populations (within England) differently to others, i.e. socioeconomic, ethnic groups and/or geographic groups.

It is expected that an ageing population will lead to much higher levels of multimorbidity and frailty. The evidence base around the management of these issues is very sparse at present, and our conceptual models of multimorbidity and frailty (how they should be described and understood) may not be adequate.

These changes have significant implications for both research and clinical practice, as they require new and proven ways of categorising patients and delivering treatments. They may also lead to new treatment aims – for example, the focus on improved quality of life over length of life or clinical outcomes, and the increased focus on ‘minimally disruptive medicine’ (https://minimallydisruptivemedicine.org/), ‘slow medicine’, ‘prudent healthcare’ (http://www.prudenthealthcare.org.uk/) and reductions in clinical activity such as de-prescribing as a response to the ‘treatment burden’ on patients.

Multimorbidity is patterned by socio-economic status, and it is important to realise that although a higher proportion of the elderly report multimorbidity, the absolute numbers are greater in the 50-70 population, especially those living in deprived areas (http://dx.doi.org/10.1016/S0140-6736(12)60240-2) The challenges are unlikely to be faced by the very old alone, and require both clinical and population-level interventions.

The organisation of health care in England is undergoing major changes (new models of care, with vertical and horizontal integration, integration of health and social care, and introduction of new providers). Nevertheless, the evidence base behind some of these major changes (such as health and social care integration) is limited. At present, we do not know which organisational changes reliably lead to improvements in outcomes. As noted recently, we also know much less about how to organise and deliver services for ageing, multimorbid populations away from urban areas, even though this may be the direction of current demographic and geographic shifts. Our evaluations of service organisation has a very restricted perspective on outcomes, with a focus on hospital admissions, and limited consideration of effects on quality of life, patient and carer experiences.

2) What do you think will be the key drivers of the changes you have described?

As noted, improved survival combined with increases in obesity and sedentary lifestyles has made a major contribution to increasing numbers of older patients with multiple long-term conditions. However, the demographic trends are complex – it was recently pointed out that the current rise in the very old represents the ageing of a very specific population (http://www.gtc.ox.ac.uk/5-academic/1903-the-four-horsemen-of-the-healthcare-apocalypse.html) and the longer term tends may differ by birth cohorts. The increasing success of medical technologies in reducing case fatality means it is unclear whether we will or will not achieve compression of morbidity for future cohorts.

3) In your view, what will be the major trends in health and healthcare in England over the next 20-30 years? (Going beyond your immediate area and expertise).

The perspective of the health services research speciality is fairly broad, and thus the issues raised above in relation to question 1 have generic relevance.

4) Are there any commonly discussed issues related to the future of health and healthcare in England which you believe to be overstated? If so, why do you believe them to be overstated?

The potential of ‘big data’ is immense, but there is a danger that the potential is not achieved because of the host of regulatory, professional and implementation issues that stand between the data, and the ‘learning health care system’ needed to use it effectively. Many of the barriers to the effective use of ‘big data’ relate to key health service issues (patient involvement, professional engagement, incentives and behaviour change) rather than technical issues. It is not that the importance of ‘big data’ is overstated, but that the focus needs to be wider to reflect the fact that ‘actionable’ outcomes require very significant changes beyond the technical architecture.

‘Big data’ has the potential to break down the traditional distinctions between research, service evaluation, and the use of routine data for service planning. This has major implications for the governance, conduct and delivery of research. In addition, developing the necessary skills to use data to improve quality and outcomes is likely to be a major growth area and will need a combination of skills (data analysis, interpretation, and implementation), which will be of relevance for both researchers and for those involved in health services management.

Some of the same challenges occur in the other major ‘arm’ of digital health – health technologies such as telehealth, apps and smartphones. Again, the potential is very high, but there are significant cases of fairly major disappointments in delivery (such as the Whole Systems Demonstrators - http://www.bmj.com/content/344/bmj.e3874, and the recent study of computerised CBT for depression - http://www.bmj.com/content/351/bmj.h5627). Many of the problems relate not to the technology, but to patient attitudes towards care and their views concerning the appropriateness of the various technologies. There is a danger that the benefits of digital innovation are transient and focussed on a small proportion of the population where real benefits may be less apparent. Commercial factors may also result in the ‘tail wagging the dog’ so that technologies are produced for problems that do not exist or are of peripheral importance adding to the risks of over-medicalization.

The speed of technological development and the ease of access to many technologies also raises major questions about the future of evaluation, and the ability of the NHS to encourage or influence standards and consistency.

‘Personalisation’ of health care is another issue which requires significant critical attention. Although there is a focus on the potential of ‘precision’ medicine in areas such as cancer, that is only one approach to the broader issue of personalisation – in terms of providing care in a way that reflects individual’s preferences and values. Innovations such as personal health budgets (https://www.england.nhs.uk/healthbudgets/) represent a very important service delivery innovation that links well to the needs of the ‘growth populations’ of the frail and multimorbid, but receives much less attention in discussions of ‘personalised’ or ‘stratified’ care. These models raise significant challenges in terms of service delivery and evaluation of outcomes. They also reveal something of a tension with the potential benefits of standardisation (http://ijhpm.com/article_3340.html).

5) Are there any issues that are underrepresented in the debates around the future of health and healthcare in England? If so, please describe them and explain why you think they merit greater attention.

Although they are represented in debates around health care, it could be argued that two critical aspects of health care delivery which are fundamental to improving health over the next 20-30 years receive insufficient focus – improving self-care as a preventive measure, and improving the management of common mental health problems such as anxiety and depression. These issues are not as glamorous as more ‘disruptive innovations’ such as technology, but a relentless focus on the implementation of proven models of care for both these issues should reap significant rewards.Brexit is likely to only have a minimal impact on increasing diversity among the population, and it is not clear that diversity receives significant attention either in clinical practice or research. In some ways, issues of diversity represent issues of personalisation writ large. What is the correct service response to diversity in populations, in terms of service provision? There are implicit and explicit incentives for services to respond to ‘local’ need and reflect the diversity of local populations, but that potential reduces consistency and may threaten to introduce inequality. Developments such as devolution will only increase these tensions.

Our systems and incentives are fairly effective at driving development of innovations in health and social care, but one of our key failings is around reliable implementation of those innovations ‘at scale and pace’. The other major failing is around decommissioning of services. ‘Waste’ in terms of both clinical care (low value procedures) and research (http://www.thelancet.com/series/research) is likely to be an important area to highlight in future debates around care.

It is important that the potential of technology (both big data and health technologies such as apps) and changes in the organisation of care (such as new care models) do not cause a shift of focus away from some of the fundamental aspects of medicine and clinical practice that remain critical to patient experience and outcomes – such as patient-centred care and continuity of care. For example, continuty of care remains highly important to patients and there is evidence that it can impact on health service outcomes such as admissions (http://www.bmj.com/content/356/bmj.j84), yet so many service delivery changes can threaten the experience of continuity.