JUNE 2000







Message from the Chairman                                                                          2


How to respond                                                                                               3


Healthcare in 2020: issues and questions                                                       4


1.                  Demand and the burden of ill health                                                   4


2.                  Organisation and workforce                                                                7


3.                  Patients and public                                                                            12


4.                  Research, Development and Technology                                        13


Panel and Task Force members                                                                   18


What is Foresight?                                                                                         22               













Health care in the UK in 2020 might be a recognisable extension of today, differ radically, or more likely be a mixture of the familiar and the unexpected. Looking back at the two decades from 1980 to 2000, minimally invasive surgery was one example of major change. Professional functions evolved with new and more prominent roles for non-medical staff such as specialist nurses and clinical psychologists. These two decades saw the last generation familiar with the inception of the NHS and who knew what health care was like before it. Over the same period commercial organisations experienced a profound transformation whereas in health care change was mostly incremental leaving many of the familiar building blocks in place. Although systems changed relatively little, progress in medicine and science was impressive and in some instances spectacular.


Health care systems such as the NHS must evolve much more rapidly over the next twenty years if they are not to lag further behind other sectors, be increasingly unresponsive to public requirements and serve as a reluctant partner to industry and academia. Building on the activities of the NHS the opportunity exists to create by 2020 a UK health care system that is proactive and in the vanguard of social and technological change.


We have emphasised the social and organisational aspects of health care not only because these are important in their own right but because they are intimately concerned with the UK’s commitment to, and success in research and development. The questions raised in this consultative document are designed to help identify key issues and opportunities in order to inform decisions taken in the short term that will shape the longer term future of health care.


We very much value your responses to the questions set out in this document and to any other comments and suggestions you wish to make.  These will be used to firm up our own ideas and help us make well-informed and imaginative recommendations for action.


I look forward to hearing from you.


Sir Michael Peckham

Director, School of Public Policy, University College London









Prevention, innovation and information are three areas key to the future of healthcare.  Effective disease prevention requires public familiarity with health issues, information on risk on a personal and population basis, and awareness of the effectiveness of early steps to maintain health. Innovation includes new technologies, new care delivery systems and novel approaches to self-management and self-help.  Essential for both innovation and prevention is the ready availability of information for better decision-making at individual and population levels, and an information-based culture to assess the impacts of new technologies and processes of care.  These three broad themes, prevention, innovation and information, are reflected in the observations and questions raised below.





1.1    In an affluent society expectations in general are high and healthcare is no exception.  This is leading to unprecedented demands on health services. By 2020 it is possible that the combination of a well-informed public and medical and technological progress will result in reduced rather than increased demand for health care at least in certain groups.


1.2    At present disease-prevention and sickness services are on parallel tracks. An integrated function is needed to focus attention on population health issues as well as the problems of individual patients.  Closer liaison is needed between social and medical sciences to address social health questions as well as the social consequences of medical advances in fields such as genetics.  Advances in medical science will open up new approaches to prevention as well as treatment.  Genetics, for example, offers the prospect of preventive strategies based on knowledge of genetic and environmental risk.

1.3           The health of children should assume a high priority since health and well-being in early life influences adult health, longevity, employment etc.  There will be an expanding pool of individuals at risk of disability, given for example the ever-improving survival of very low birth weight babies where community care will play a key role.  At the same time there will be increasing understanding of brain development in early life.  It will become clear that a focus on early mental and physical development is an important investment for society.  Provision will be needed to ensure that all children receive the appropriate stimulation and education in the pre-school period.


1.4    Health is influenced by policies in sectors other than healthcare, for example housing, transport, environment, employment, energy, criminal justice, education and welfare.  Transport, accidents and the health effects of air pollution may be seen as examples of direct effects and reduced physical exercise leading to greater obesity as indirect.  In the UK and worldwide, socio-economic disparities between rich and poor are key determinants of health, quality of life and death rates.  Unsustainable patterns of development are increasing the gap in wealth and health between rich and poor.


1.5    By 2020 we can expect therapies for conditions where little or no treatment exists today.  Included here are interventions for pre-disease states, for newly-defined problems, for existing intractable illness, and for new disease entities.  Elucidating the biological basis of disease brings closer the prospect of novel preventive interventions.  New pharmaceuticals will come on stream for conditions where no or few treatments have existed for example, chronic neurological illness such as multiple sclerosis.  Greater understanding of minor mental dysfunction could lead to new treatments and increased demands.


1.6    The opportunities for screening for early disease or disease risk will increase and the pressures for screening will be intense.  Screening is expensive and it can generate substantial downstream health service activity, alternatively it might substantially reduce the cost of preventable disease.  Although the gains could be enormous, screening can also create harm and has the potential to discriminate against individuals or groups.


1.7    Substantial progress is anticipated against chronic disease and disability. The historical focus on acute problems will shift and by 2020 chronic disease management and symptom control will be highly developed. Notwithstanding medical progress there will be increased numbers of older frail people with social care needs where the pressures of isolation and anxiety will increase the chance of physical and mental illness.  Although home-based technologies will help to alleviate the need for care, for the potential of new technologies to be realised access to and uptake of preventive measures for example against osteoporosis or dementia must be assured.  Otherwise we could see a widening gulf between informed and empowered groups and other sectors of society.  Highly developed chronic disease and disability services integrated with good primary and secondary prevention will be key components of future health care.  This will require a shift from reactive to proactive health care.


1.8    Recrudescence of infectious disease and the problem of super-resistant organisms highlight the pressing need for new antibiotics and vaccines.  Research into anti-microbial treatments has increased and new avenues of exploration are opening up through microbial genome sequencing.  At the same time the UK has an excellent opportunity to develop novel vaccines that could also find application in contraception, cancer and auto-immune disease.


1.9    International surveillance of infectious disease and other health problems will be increasingly important to supplement the systems appropriate for surveillance at national level.




2.1       Voluntary organisations and voluntary action contribute substantially to health care.  We anticipate an increase in voluntary sector participation in the provision of care and an increasingly proactive stance with regard to health care research, policies and practice.  We also envisage the formalisation of relationships between the voluntary sector and government and between the voluntary sector and health care industries.


2.2       Increasing expectations and knowledge might lead to novel specialisations, for example genetic diagnosis and counselling, or stem cell culture and tissue regeneration for injury and disease.


2.3       On the basis of current trends professional roles are likely to be transformed over the next twenty years.


2.4       The NHS has traditionally depended on imported labour across the range of health professions, doctors, nurses and ancillary staff.  Demographic changes appear likely to increase demand for such staff over the next 20 years.


2.5.      There is evidence that team-working enhances performance, improves results and protects staff against stress.


2.6       High stress levels in staff will be an increasingly unacceptable aspect of health care.


2.7       The future healthcare system will be based on a fundamentally different relationship between user and provider and between government and service.  This requires a change in culture and systems. It will also highlight the need for the highest calibre professional leadership to ensure amongst other things enlightened and transparent professional regulation, continuously updated and responsive education and training, and the active inclusion of all staff in questions relating to the service they work in.


2.8       Interpersonal and listening skills, acknowledging the contribution of the expert patient, mutual respect between members of multidisciplinary teams, together with a problem-solving learning culture are essential for high standard care.  In the education and training of doctors and other staff creating conditions for learning, unlearning and relearning will be crucially important.


2.9       Healthcare systems lack in-built safety mechanisms.  This results in errors which cause unnecessary morbidity and mortality and waste resources.  Responses such as litigation contribute to a blame culture, which in turn inhibits innovation on which medical progress depends.


2.10     Incentive structures for optimising the results of health care are poorly developed.  In other settings methods such as mechanism design and game theory have been of practical value.


2.11     Home-based health and social care, domestic help and support and effective, responsive out of hours services could shift the treatment of chronic physical and mental ill-health into environments more conducive to recovery or better quality of life.  Achieving this requires a fusion of health and social care.


2.12     The management of information and knowledge opens up spectacular opportunities for service productivity, for patient information and choice and for industrial and university partnerships.  Informatics opens up new possibilities for research in healthcare, for example through the use of data mining, numerical modelling tools, geographical information systems and curation methods to monitor quality of delivery and outcome of care.  However, the information needs of clinicians, patients and the public need to be much better defined.  Technologies and processes designed in relation to those needs are much more likely to be useful than those based on assumptions about professional and user requirements.  Data protection and confidentiality are important but overzealous concern could inhibit decision making and innovation including the commercial exploitation of medical discoveries.  Top-down monolithic IT initiatives can be fraught with difficulty.  Long-term evolutionary strategies need to be combined with initiatives to improve the quality and flow of information locally drawing on the know-how of staff and using existing information systems and channels of communication.



2.13     Between 1948 and 2000 there has been a consensus that UK healthcare should be financed collectively for all the population and distributed according to need.  The freedom for individuals (or employers on their behalf) to purchase private medical insurance, or pay for health care directly has also been upheld: approximately 11% of the population are covered by private insurance.  A publicly-funded, nationally-coordinated service with universal coverage and universal registration has potential advantages other than equity, access and preventive care.  It should for example be ideally placed to facilitate large scale epidemiological studies designed to elucidate genetic and non-genetic disease risks.  It should provide a high-quality test-bed for the conduct of clinical trials and longitudinal studies.  The information base could be of inestimable value and it should be well placed to permit discriminating use of blood and tissue samples for example to relate genetic sequencing to clinical data. By designing and testing lower-cost preventive or therapeutic interventions there could be significant export potential as well as national benefits.  A publicly-funded service should be strongly placed to integrate public health and clinical medicine and to develop functional interfaces with the educational and other sectors.


2.14     Health care is expensive and increasingly so.  Traditional ways of resourcing may be inappropriate for future needs.  Alternative forms of financing can be found in other EU countries.  Some maintain a large role for the public purse, for example through hypothecated taxes, voluntary top-up tax, social insurance or medical savings accounts.  Others place greater reliance on non-state sources including higher user charges, private medical insurance or greater use of private finance in capital projects.  In both cases the state necessarily retains final responsibility for equity of access.


2.15     British culture has placed high value on providing equitable health care.  In practice this has meant equity of access rather than equity of outcome. To achieve equity of outcome requires a proactive service to overcome problems such as delayed presentation of disease.  Access to information about options and results will place irresistible pressure to ensure genuinely equitable services.  The ability of people to access health and social care in the future will be influenced by their current situation for example their occupation, financial status, lifestyle etc.  Poverty causes ill health and not paying into a pension scheme means a lack of access to an adequate pension income.  How many women for example will not have access to adequate pension income either from their own provision or from their partner?  Some ethnic minorities are disadvantaged with the ageing ethnic population presenting a particular challenge. Language and access to information could be significant barriers to healthcare for older people.


2.16     In primary care more than 20 different languages may be spoken by patients attending in any one week.  Meeting the needs of complex multi-ethnic communities is not solved by traditional structures and systems.


2.17     Telephone and internet-based advice, and walk-in and work-based clinics will increase choice at a potential cost of compromising continuity of care.


2.18     There could be growing public demand for 24-hour services.


2.19     One scenario depicts a future in which clinical decisions are supported by intelligent systems, home-based care will draw on easily accessed information, monitoring systems and novel assistive and diagnostic techniques and community clinics will employ chip-based technologies, electronic links to specialists, low cost imaging and minimally-invasive surgery.




3.1     Doctors are seeing an increasing number of better-informed patients with access to health information via the internet, who are prepared to challenge professional opinion.  Health professionals will need to know the limits to their knowledge and be able to access and interpret relevant information.  The opportunities exist for a profoundly different and better patient/doctor relationship although there is also the risk of adverse effects and conflict.


3.2            Patient involvement in their own healthcare can improve outcomes. Related to this is the need to distinguish between high and low quality information, and ease of accessing it.  Patient empowerment is not only about information but also advocacy and support.


3.3     Genetic diversity will underlie some diagnoses and be fundamental in proposing specific preventive treatment regimens.  The integration of genetics into public understanding and its appropriate use in professional decision-making are fundamental issues.


3.4     Genetics raises the more general question of the understanding by the public of science, engineering and technology including clinical trials, the rationale and benefits of experimentation in medicine and concepts of risk. A well-informed public could exert an important influence on the support of fundamental research and industrial research and product development.  A fresh departure is needed for public education in relation to health.  This might be through school and university curricula, through the internet, and through the media.




4.1     Many of the advances in engineering, technology and the social, physical and biological sciences over the next 20 years will be at the interface between subject areas, for example between biology and engineering such as tissue engineering. 


4.2       Some of the most revolutionary changes in health care will emerge from activities at the interface between subject areas and sectors.  Most if not all of the foresight panels are considering issues relevant to health and health care. 


4.3     Healthcare subtends a wide spectrum of technologies from widely different sectors such as aerospace and astronomy.  Exploiting new and sometimes unexpected technologies will be essential to create new and better forms of care.  The UK has established a strong platform within the biotechnology/life sciences sectors with industry playing its role alongside Government.  However, there are barriers to the exploitation of discoveries and technologies in the UK.  A culture of innovation and risk is less developed in the UK than in the US, a problem exacerbated by a lack of development support beyond venture capital.  The potential exists to accelerate in a discriminating and well-planned way the entry of new technologies into care.  Resistance to experimentation will constrain progress in the UK.  The UK is beginning to build the environment to create new technologies and to promote high-risk innovation.  To fulfil the potential of the momentum that has been achieved, by 2020 the UK healthcare system, academia and industry need to be much more closely aligned so that discovery, product development and health care provision are seen as three elements of one endeavour.  “Holistic” methods are needed to measure the health, social, economic and other benefits of new technologies and to incorporate prospective assessments into the policy-forming process.


4.4       Technology transfer should be removed from university administration and developed through an organisation that understands technology and how to handle, manage, package and market it.  Technology transfer should be developed as a profession.  By 2020 perhaps most of UK health care intellectual property including that of the NHS should be handled by a professional technology transfer capacity.  An option might be to create an Applied Research Council which would take over from existing research councils the funding of near-market research.  This would allow the other bodies to ensure that research aimed at new discoveries was sustained and strengthened.  The remit of the Applied Research council would be to fill the development gap between research and proof of principle by awarding grants to higher education institutions including the support of patent expenses.


4.5       Research necessitates regulation but regulatory burdens are escalating. It is possible, and in some cases likely, that this will encourage R&D activity to migrate to countries where regulatory arrangements are more favourable.  As it is often expedient to locate full-scale production plants close to the site of pilot studies there is a heightened risk that advanced manufacturing and technologies will be lost from the UK.  Current regulatory frameworks covering animal research need streamlining. Clarification is needed on the ownership of organs and tissues and consent to research.


4.6       Understanding cell differentiation pathways will allow tissues to be grown from stem cells and opens up the prospect of growing human organs. Knowledge of cell signalling mechanisms will help develop methods for repairing wounds and replacement for conditions such as stroke, dementia and heart disease.


4.7       The use of animal organs (xenografts) for transplantation into human subjects may cause public apprehension even if the potential hazard of viral infections proves not to be a problem.  However xenografts may be the most feasible option for those waiting for complex organ transplants, especially heart and lungs.  Ethical considerations, along with risk and benefit studies, need further attention.


4.8       The potential applications of tissue engineering and related technologies continue to expand.  The combination of a national health service, blood transfusion service and the availability of tissue banks, constitutes a unique resource and offers the potential of handling the cells and tissues of individual patients for transplantation and related purposes.  One possibility would be for the NHS itself to create a clinical research organisation.  It has the skills and potential to do so.


4.9       By 2020 functional imaging of the brain will have made great progress shedding light on normal function, intelligence, behaviour and the characterisation of genetic risk factors in neurological and psychiatric illness.  Brain cell transplantation will have widening applications and there will be a greater understanding of the biological basis of schizophrenia and other serious mental disorders.  Some conditions notably dementia will be diagnosable a decade or more before they become clinically manifest.  There will be substantial expansion in the number and range of neuro-pharmaceuticals.  At the same time there will be greater demands for non-pharmacological treatments such as interpersonal therapy.  Nurses will assume a greater role in prescribing and there may be a new cadre of community-based carer.  There might also be a greater involvement of voluntary workers in mental health.  This is an arena where cutting edge science, new product development, evolution of professional roles and an emphasis on community problems are all intimately connected.



4.10     Sequence data on the human genome will be available in the near future. This opens up opportunities for elucidating disease mechanisms, for diagnosis and disease classification, for identifying genetic and non-genetic risk factors, for the targeting of existing treatments, for conducting clinical trials on more homogeneous subsets of patients, for developing drugs in relation to genetic targets, for tailoring drug dose in relation to toxicity and for gene therapy.  While the potential applications and benefits of genome research are clear, the actions required by the health service, government, the universities and industry need more precise definition.  The Medical Research Council and Wellcome Trust Biomedical Collections initiative is encouraging.  There is a unique opportunity for the NHS to exploit to a much greater extent its large patient cohorts linking strong epidemiology to genetics, a strong academic base and a good post-genomic base.


4.11     The collation and use of genetic data raises ethical questions which need to be addressed promptly.



4.12     The Human Genome Project and the research that follows will necessitate the handling of huge amounts of data.  Dealing with this complexity requires the development of new mathematical models, with appropriate bioinformatics support.  The task of determining how genetic factors relate to physical or mental dysfunction and disease is already underway. Currently there is no real breadth of epidemiology to integrate human genome data with clinical features.  Shortcomings in mathematics and statistical biology will prove to be a constraint unless overarching mathematical models can be established.  Inappropriate use of low quality data is one of the biggest threats to patients and to progress.