HEALTHCARE IN 2020
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?
MESSAGE FROM THE CHAIRMAN
HEALTHCARE IN 2020:
MORE OF THE SAME OR TRANSFORMED?
Health care in
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
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.
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.
4.4 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
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.