Future NHS: the heat is on

Who in 1948 could have predicted the shape of the NHS today? Many once believed it would advance health so far it would be out of business by now.

Crystal-ball gazing for the next 60 years is just as hard. But science and society point to some of the directions we will move in.

This is the basis for the predictions of futurologists. These largely US-based gurus spend their lives considering what challenges we will face and predicting where creativity will take us in solving them. They seem agreed that change will accelerate, opening up innovations in many fields affecting healthcare and leading to longer and healthier lives.

Earlier this year the US National Academy of Engineering unveiled its biggest challenges for the next 50 years, developed by an 18-strong team of scientists, entrepreneurs and thinkers.

Its report said: "As the population grows and its needs and desires expand, the problems of sustaining civilisation's continuing advancement, while still improving quality of life, looms more immediate. Old and new threats to personal and public health demand more effective and more readily available treatments. Vulnerabilities to pandemic diseases, terrorist violence and natural disaster require serious searches for new methods of protection and prevention."

Its gurus forecast new clean energy sources, a need for people and organisations to purify their own water and "personalised medicine" using drugs tailored to an individual's own genome.

Ray Hammond, futurologist and author of The World in 2030, predicts robots to look after elderly people living at home while others talk about incision-free surgery, grown-to-order transplant organs and nanorobots embedded in the body and brain, enhancing health and intelligence.

More concretely, the Bill and Melinda Gates Foundation is funding research to meet some of our greatest health problems, including needle-free vaccines that do not need refrigeration.

Over the next four pages we present the challenges HSJ's crystal ball revealed for the NHS: our shifting demography; the evolving internet; advanced genetics and global warming.

Demography: people power

The UK population is both growing and ageing. It currently stands at just over 60 million but by 2051 it is estimated to be 65.4 million, with a quarter aged over 65. The number of very old (those aged over 85) is also likely to be much greater - predicted to hit five million by 2031.

That has profound implications for the NHS and its workforce. The top worry is the rising number of people with Alzheimer's disease and other forms of dementia.

Age Concern policy manager Philip Hurst says: "There will be more people with more health needs - and more complex health needs. But the other thing to think about is that people with dementia will have multiple co-morbidities."

It is going to require a new breed of clinician to respond, he argues. "What we will need is a generalist who can make a comprehensive assessment and work out what to treat and what not to treat. At the moment we have increasing specialisation that is creating people who treat conditions independently of each other.

"I think in the future it will be impossible to be a good cardiologist, for instance, unless you also have a thorough understanding of dementia."

Mr Hurst does not see anyone addressing this. "There is a really fundamental point here. The workforce development agenda at present is being led by professional aspirations rather than predicted health population trends. That needs to change or we will end up with a set of professionals that is increasingly irrelevant to the population they are expected to serve."

There will need to be a new emphasis on joined-up housing, health and social services, he adds, as well as planning for end of life services. With more people come more deaths.

With the number of young declining relative to the older population, there are likely to be some extensive staff shortages. National director for health and work Dame Carol Black says the NHS will have to respond by looking after its workforce.

"The competitive attractiveness of the NHS will increasingly be determined by the care shown to staff," she says. "In a globally competitive world for people with high skills the NHS will find it increasingly necessary to nurture and support its staff in all matters that affect their health and well-being and to demonstrate that they are doing so."

That is going to mean paying more attention to work-life balance, particularly as the number of women in the healthcare professions is set to grow. It could also mean - as the CBI has proposed - people working to 70 or beyond.

There are other changes afoot in society, adds Dame Carol. "One of the most significant changes lies in new concepts of medical professionalism and the ways doctors and society understand the nature of the profession and the professional role today."

Among the factors at play are questions about the nature and boundaries of the responsibilities of different members of clinical teams and the roles of doctors within clinical teams.

"It is now accepted that there is a pressing need to support closer participation of doctors in management with strengthened leadership at every organisational level," she says.

These predictions about demography are based on what is happening now, but of course that could be a long way from what actually happens. Futurologists are predicting longer, healthier lives, with one US body, the Methuselah Foundation, researching whether people could live to 1,000 years. Mr Hurst admits such a scenario cannot be planned for. He points out that it is average life span that is increasing, not absolute ages. The oldest of the old are no older than they have ever been; there are just more of them.

The more realistic prospect is that people will stay healthier longer, or at least that the NHS will redouble its efforts to promote lifestyles that seem to deliver healthier, longer lives.

What will be acceptable in future under the banner of public health? Outlawing smoking? Differential charging for people who deliberately put their health at risk by smoking or drinking?

Tony Gilland, science and society director at the Institute of Ideas, says a hazard is emerging in the current trajectory on public health: "I think there is a real danger the NHS will become sidetracked by people's lifestyles," he says.

"What we have seen in relation to the panic about obesity and alcohol is the politicisation of healthcare and it shows no sign of abating. The NHS is getting dragged down the route of modifying people's behaviour, which is highly problematic."

The NHS is increasingly using social marketing tools to identify groups of people to target with health messages, for example.

Mr Gilland says: "The evidence base for public health interventions being effective is very low. Politicians tend to ignore this. There is also a major problem in terms of democracy and citizenship. It undermines the concept of the autonomous citizen."

Genetics: a new generation of bio-informatics

In 60 years every person in the UK could have their own unique genetic sequence recorded in their electronic personal health record.

"The US National Institutes of Health has set a target of creating a personal genome sequence for a cost of $1,000 by 2015 and it looks as if we are on track to achieve it," says Rob Elles, chair of the British Society for Human Genetics. Just this year scientists have created the first personal genome sequence.

North West regional genetics service consultant clinical geneticist Dian Donnai agrees: "The next generation of sequencers is nearly with us. These are incredible machines that can do a whole genome sequence. There is no doubt that long term this is a reality for diagnostics in the NHS."

The implications of this for medicine, the NHS and society are not yet clear. Science is at the beginning of understanding what a person's genetic sequence will tell us.

As Dr Elles puts it: "Quite how or whether you can make use of such a sequence is the bigger question."

"Until fairly recently genetics was about chromosomal abnormalities," Professor Donnai explains. "It was clear many common diseases such as cancer and heart disease or diabetes involved family tendencies but we have never been able to pin it down."

That is now changing as geneticists start to unravel and pinpoint the factors for risk in some forms of heart disease, cancers and so on.

And with the knowledge comes the ability to do something about it; first to predict who might be at risk and offer advice about how to minimise risk, and then to develop treatments.

"Once you know the gene you can work out the protein it encodes for what pathway it operates in and then identify more genes and understand the biology," says Professor Donnai. "Then you can look at targeting treatments."

This thinking is already at work in trials for new treatments for Marfan syndrome, a genetically linked form of heart disease. It is also behind talks about implanting defibrillators in people at risk of certain inherited heart arrhythmias.

There is also emerging evidence that different people respond to different drugs because their genetic make-up varies, leading to a future discipline of pharmacogenetics.

"People do metabolise drugs differently," adds Professor Donnai. "It will no longer be the right drug for the right disease but the right drug in the right dose for the right patient with the right disease."

For the NHS, Dr Elles points out, one of the current challenges is the increasing speed at which it is possible to translate exciting research into practice. "We exist in a publicly funded health service so our focus is on the most effective and best value interventions. [We need] a mechanism to benchmark new diagnostic tests that are potentially becoming available, to make sure they are adopted and lead to better treatments."

Then there are the public health considerations. Dr Elles warns: "The risk of testing for a condition and saying to 10 per cent of the population that you are at enhanced risk of, say, heart disease, is that by implication you are telling 90 per cent [that they] in some fashion have a licence for risky behaviour.

"There are some very complex decisions in a public health context and it is not well understood how this will play out. But you can't take away the potential for people to have that knowledge."

All this will have a profound impact on society and is being considered by the likes of the Nuffield Council on Bioethics as well as a House of Lords inquiry. Others like Nowgen, the centre for genetics in healthcare of which Professor Donnai is a member, are developing public engagement to stimulate the debate.

The missing piece of the jigsaw so far is the likely impact on the NHS workforce.

Dr Elles says: "This is going to be a huge challenge. We are going to need to develop a whole new generation of bio-informatics scientists who can work in a service context.

"Doctors and nurses are going to need a new grounding in genetics and biochemistry to understand disease processes. This has to be actively pursued and right now very little is being done."

Global warming: NHS emissions

The New Economics Foundation think tank places the NHS as one of the world's biggest and most resource hungry public sector institutions, emitting around a million tonnes of carbon a year. Some 5 per cent of the UK's road emissions are attributable to NHS-related journeys with 25 billion passenger kilometres racked up every year by patients, staff and visitors. Over 80 per cent of this is by car.

The NHS also generates one in every 100 tonnes of domestic waste, most going into landfill, where it generates more atmosphere-damaging gases.

The NHS already has targets in place to reduce energy consumption by 15 per cent from 2000-10; the Climate Change Bill will see that become even more stringent over the next 40 years.

To achieve this the health service could provide healthcare closer to home in energy-saving buildings. It could also become paperless and buy food for patients locally.

The effects of doing nothing were spelled out in a report for the Department of Health in February. Its gloomy outlook was of more flooding and threat of water-borne disease. Heat waves pose a real threat and skin cancers will increase with hotter weather. Malaria could reappear here, and tick-borne diseases will be more common. Air pollution will worsen, aggravating breathing problems.

Friends of the Earth climate change campaigner Robin Webster says: "It's not just the immediate affects of catastrophic events such as flooding or storms that would impact the NHS. People lose their homes and there is a threat of societal breakdown."

The global impact would also be felt. "Food supplies are extremely dependent on international linkages," she adds.

With the global population set to hit 9 billion by 2051, there will in future be unimaginable pressure on resources such as food, land and water. Increased conflict around protecting such resources is strongly predicted.

"We are really at a crux moment," says Ms Webster. "Global warming is going to have a long-term impact on the health of the nation. That's why it is important the NHS does understand and respond to the threat."

The internet: the patient in control of information

Web 2.0 is the new generation of internet user interactivity and Google, Microsoft and Intel have all made multibillion dollar investments in web 2.0 health resources.

"The implications of web 2.0 on the health service are potentially hugely disruptive," says Jon Hoeksma, editor of the website E-Health Insider, which recently published a report on the subject. "But like the cyberpunk [author] William Gibson says, 'the future's here already, it's just unevenly distributed'. Small bits of web 2.0 can be used now fairly simply and fairly cheaply and anyone in healthcare should be playing around with the new technologies."

In fact what is here already is quite limited but it points us to a radically different future.

Mr Hoeksma explains what he means by web 2.0. "It's a catch-all phrase to describe sites which enable people to generate content and write material and review it, to connect with each other and to network."

"This is like the [computer] gaming industry 15 years ago," says Mr Hoeksma. "Compare what was offered by the first electronic tennis game with the sophistication of new games. That's where we are headed."

He envisages patients holding individual budgets and needing information about providers and treatment options.

"I do not think [the information provider] will be the NHS or the Department of Health," continues Mr Hoeksma. "I think we will see independent sources emerge. Even at this stage the power of networks is being felt incredibly rapidly."

Not convinced? Look at the explosion of networking sites such as Facebook and Bebo. Or take a look at www.patientopinion.org where patients write their own experiences of NHS providers. Its slogan is "This is our NHSƒ let's make it better".

Mr Hoeksma says all this activity is beginning to create a genuine feedback cycle into the NHS.

The next big area is personal health records. Google has stepped into the arena offering US residents an online patient-controlled health record.

"Think of it like a bank account. You choose what information goes in and comes out and who has access to it. It has huge potential for the future," says Mr Hoeksma.

Such a scheme solves the problem of centrally held health records by handing over the issues of privacy, confidentiality and access to patients. "It puts the patient in control of their healthcare information."

One criticism is that this will widen the digital divide. Mr Hoeksma agrees but adds: "It does not take 100 per cent of society to make quite dramatic changes."

The development of health informatics was one of 14 challenges for the next 50 years identified by the US National Academy of Sciences this year.

Delivering personalised medicines - as predicted by the advances in genetics - will need new ways to track patients' biological records. For example, electronic patient records could build in genetic profiles that tell doctors how you might respond to certain drugs or what conditions you are likely to develop.

It is an area riddled with ethical and moral minefields. Even so, Partners HealthCare, a US health system, is already starting to do just this.

Alongside this development is the notion of personal health systems: devices that monitor say your blood pressure or heart rate. Telehealth is already here - patients monitor themselves at home and results go up a telephone line to a website accessible by a clinician for review. The technology is moving from pilots with hundreds of patients to those with thousands.

The next step, says Mr Hoeksma, will be to transform this into "Jiffy bag" technology - something so easy to use you can send it through the post and the patient can get it up and running.

Intel is now taking this next step and by the end of the year, with Continua Health Alliance, it expects to have brought consumer personal health devices to market.

In future much smaller devices might be implanted, perhaps monitoring exercise and food and alcohol intake.

So, a future where patients hold their own records, monitor their own health and choose their own providers and treatments based on their peers' views. Now that is radical.