Mark Riddaway says 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 would 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, our aspiration ought to be to have as little to do with them as possible. And yet our entire health system – together with the research that supports it, and the political structures that determine its priorities – is heavily 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 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,’ goes far beyond the usual personal rebukes: eat less rubbish, run more, stub that ciggie out. But its conclusions are far more nuanced than that. “This project isn’t simply about what people call ‘lifestyle choices’,” explains Professor Johnson. “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. “We’re trying to say that if you really think about things that make for a healthy public, they go 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.
There are many factors that will determine how healthy the British public will be in 25 years: climate change; the growth of cities; emerging technologies; the changing nature of work; 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 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 many complex inputs, one clear trend is bound to have a huge impact on shaping the nation 25 years hence: increased life expectancy. “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 suggest that the size of the working-age population in 2040 will be broadly similar to that of today, while older generations will be disproportionately large. The number of Brits aged 75 and over is projected to rise by 89.3 per cent, 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.
While people are living longer, our ‘healthy life expectancy’ (time spent in either ‘very good’ or ‘good’ health) is not increasing at the same pace. “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.”
Another vital ambition, she insists, should be the reduction of inequalities in health. 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. For example, 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. While we’re living longer, we’re not reducing that gap.”
Professor Johnson and her colleagues have concluded that far greater investment in prevention research is required if meaningful changes are to be made. We need, she says, to develop a better understanding of the wider determinants of health – 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 per cent of the total,” says Professor Johnson. “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 per cent. A large part of this seismic shift has come through improved biomedical understanding: more effective blood pressure control, 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 well understood. “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.”
As well as requiring more substantial funding, prevention research would benefit from a shift in emphasis, from observational to interventional – solving problems rather than simply describing them. Efforts should be focused on interventions that can be applied to populations, systems and organisations, rather than individuals. And evaluation of these interventions needs to be of the highest quality, offering a proper assessment of both efficacy and cost-effectiveness.
For researchers, the opportunities offered by the ongoing digital revolution could be vast. In a process that is proving both cumbersome and costly, our medical records are gradually being digitised, meaning that opportunities for interrogating large medical datasets should expand significantly. Even greater potential could be unlocked if this medical information were to be matched with the data collected by private companies every time you switch on your smartphone, browse the internet or pay for your shopping.
“Think about supermarket loyalty cards – they have so much information about what people eat and drink and how much they spend, which would 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? We need to start 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 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. “The starting point for health of the public research is understanding how the various levers you can use will alter human behaviours. How you use them and how much you invest in them are ultimately political decisions.”
These decisions should, she says, be driven by long-term health outcomes rather than short term budgeting. “Fiscal policy might be measured largely on whether the country gets richer, but you also have to take into account the impact of that policy 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.
Public health and clinical practice also need to become more closely aligned, with doctors trained to better understand prevention, population data and competing risk. “There are discussions already underway about reframing academic career pathways. I’m in talks with a number of medical schools 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.