Recent spectacular advances in medical discovery science should lead to huge increases in life expectancy. The global population of over 65-year olds will double by 2050 and for the current generation, living past 100 years of age may become routine. This will have fundamental implications, not only for the individual, but also for all aspects of society. Population demographics, infrastructure needs, social interactions, working patterns and future prosperity will be defined by how ‘well’ the population ages.
What appears at first sight to be a rosy future is, however, threatened by the emergence of an epidemic of chronic non-communicable diseases (NCDs), such as diabetes, heart disease, cancer and dementia. By 2020, these are forecasted to account for 75% of deaths worldwide, so that longevity may become a burden rather than a benefit. Living longer with illnesses drains resources, compromises productivity and reduces quality of life. An unhealthy population is expensive – for Government, for businesses, for communities and for individuals. Globally, US$47 trillion of cumulative economic output will be lost between 2012 and 2030 because of the impact of chronic ill health.
Mikhail Fridman has introduced the term ‘indigo generation’ to describe those who will shape tomorrow’s economy and help to create national wealth. The challenge for healthcare will be to ensure that they, and future generations, not only live longer but can fulfil their potential by remaining healthy and productive. Many of the conditions, which are responsible for premature disability and death, are the consequence of deterioration in lifestyles, including sedentary behaviour, excess calorie consumption, poor diet and smoking. They are, in many cases, avoidable. In order to address this, the goal of healthcare needs to change from ‘disease management’ to ‘wellness maintenance’.
Investing In Your Arteries: “Prevention Is Better Than Cure”
Health economies everywhere are struggling with unsustainable costs and rising demand. The prevailing assumption that this can be solved simply by throwing more money at the problem, needs to be challenged. Three factors underscore a requirement to focus on prevention: economic imperative, novel understanding of diseases and opportunities from the digital revolution.
Cardiovascular disease is a compelling example of the need to ‘move upstream’ in intervention, as it both shortens life expectancy and degrades quality of life. It accounts for 31% of all global deaths, mostly from heart attacks and strokes, and furthermore is a major driver of health inequalities.
It is now appreciated that the first signs of arterial disease can already be detected from childhood, with evidence of damage to the lining of arteries, present from as young as five years of age. In the USA, a study showed that 20% of teenagers and 85% of individuals of 50 or older who died of non-cardiac related problems, such as road traffic accidents, already had significant disease in their coronary arteries. This silent, ‘pre-clinical’ phase of the disease is driven by risk factors with which we are all familiar, such as high blood pressure, cholesterol, smoking and diabetes. Genetic studies have shown that maintenance of lower levels of these risk factors from a young age, can prevent many of the late cardiovascular problems, supporting the arguments for lifetime health management. I call this ‘investing in your arteries’, as the approach is analogous to personal financial planning. You would not be advised to start saving for retirement when you are 64 years of age! When we meet our doctors, we are often told that it is “never too late”: but the real message should be that it is “never too early”.
A second compelling reason for early ‘investment’, is the increasing evidence that the same risk factors and ‘bad behaviours’ that drive cardiovascular disease, also increase the risk of dementia, cancer and diabetes, through shared biological pathways such as chronic inflammation. Treatment of gum disease, a common source of inflammation, has recently been shown to improve arterial health, diabetes control and kidney function. Simple, early lifestyle improvements may therefore be an effective way of optimising healthy ageing and reducing future risk of a broad range of important diseases.
The digital revolution is only now beginning to have a major impact on healthcare, and its scope is limited only by imagination. Different countries are at different stages in the digital journey towards more data-driven, personalised and efficient care. Assisted by Artificial Intelligence and Machine Learning, real world monitoring of public and patients through wearable devices will permit improved risk prediction, management and treatment.
What Needs To Happen?
A focus on reducing clinician burden is required, with more efficient use of existing resources for treatment of patients with complex diseases, and a move to wellness evaluation outside the traditional medical environment. However, a major challenge for healthcare systems will be to redefine the relationship with the public, who have developed unrealistic expectations and dependence on ‘downstream’ rescue treatments by doctors. In the UK, the NHS currently spends £97bn of public money on treating disease and only £8bn on prevention. Its future, and indeed that of any health care system, will hinge on empowering people to take ownership and responsibility for their overall health. Their choices, which are influenced by understanding and life circumstances, affect ‘lifetime wellness’ more than the impact of health care systems. The best way to ensure the future of the NHS therefore, is to use it as late as possible!
“Focusing on the responsibilities of patients isn’t about penalising people, it is about helping them make better choices, giving them all the support we can, because we know taking the tough decisions is never easy.” – Matt Hancock, November 2018
A key step to achieving a ‘New Partnership’ between healthcare professionals and the public, is effective communication of both risks and health opportunities. Traditionally, the medical profession has struggled with this. In the UK, we have recently developed a novel digital tool which allows people to calculate their ‘heart age’ and this has been enthusiastically taken up, with more than 3 million users on the first day of its launch. This demonstrates the public interest in understanding their personal health, and will need to be followed up by efforts to incentivise sustained behavioural change.
A New Deal?
It is gratifying that the issues of health maintenance and disease prevention are now being publicly debated, with high level political engagement. Prevention is moving to the heart of NHS strategic planning.
“We need to move from a system that detects and treats illnesses to one that also predicts and prevents poor health through promoting health in all policies and puts people back in charge of their own health” – Duncan Selbie, November 2018
Previously concerns about voter reaction has limited discussion. Studies however, have shown that the public are willing to consider and support change, even if it involves increase in taxation, providing that it leads to visible investment and improvement in healthcare.
It is not, however, as simple as it might seem. Ill health is not just the result of bad genes or bad choices, but also of bad environment. Government resources will need to be directed towards improving transport, housing, education, work place and urban planning, as well as air quality. Furthermore, more money allocated to prevention, will not automatically unburden front line services. A new ‘deal’ between health care providers and the public is needed. The Government and health professionals must partner, to deliver evidence-based guidance on health and fund and deliver a top-class ‘disease care system’ if and when it is needed by patients. At the same time, the public should view their health as their most valuable asset and adopt behaviours to maintain it.
“It should be the function of medicine to have people die young as late as possible” – Ernest L. Wynder M.D