Foresight
HEALTHCARE IN 2020
HEALTHCARE PANEL
CONSULTATION
DOCUMENT
JUNE 2000
CONTENTS
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
MESSAGE FROM THE CHAIRMAN HEALTHCARE IN 2020: MORE OF THE SAME OR TRANSFORMED?
Health care in
the
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
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,
HEALTHCARE IN 2020: ISSUES AND QUESTIONS
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. DEMAND AND THE BURDEN OF ILL HEALTH
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
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
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. ORGANISATION AND WORKFORCE
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
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 PATIENTS
AND PUBLIC
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. RESEARCH,
DEVELOPMENT AND TECHNOLOGY
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 UK UK US UK UK UK
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
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
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.