Like the poor, the sick don’t have to be always with us.

A NESTA debate on The Health Foundation pamphlet Health in 2040 about the future numbers of people with major illnesses.

This morning I’m taking part in a really important debate – where I am the smaller part of that debate.

Last July the Health Foundation published Health in 2040 projected patterns of illness in England authored by a range of people including the excellent Anita Charlesworth.

This is an important publication. It goes into much more detail in describing how the demography of our society and its illnesses will impact on the NHS.

All of us agree that, over the next 15 years, there will be an increasing proportion of the population that are aging. Nearly everyone believes that this increased proportion of the population that is older, will have more people who have illnesses, and that it will lead to increased demand on the NHS.

All of the recent plans for the future of the NHS, from the Times Commission, Reform, everyone, argue that their plans are based upon this assumption.

This pamphlet goes into this in forensic detail,

“Between 2019 and 2040 the population is projected to grow by 3.5 million with almost all of the increase among people aged 70 years and older. In addition to this demographic shift the average number of years people spend living with major illness is projected to increase. …The age at which people are expected to be living with major illness is projected to stay the same life expectancy is projected to increase this means on average people are expected to live longer with illness”

Page 5

The pamphlet then goes on to work through the implications of a small increase in life expectancy on the overall burden of illness.

Between 2019 and 2040 the number of years that older people live with a major illness increases from 11.2 to 12.6 years. This relatively modest increase over 20 years in fact means that the number of people living with a major illness increases to 1 in 5 of the population.

“Overall, the number of people living with major illnesses is projected to grow by 2.5 million from 6.7 people million people in 2019 to 9.1 million people in 2040 an increase of more than one third.”

Page 7

These are startling and very important figures.

Over the years I have never known Anita’s grasp of facts about health and health care to be wrong so what am I debating with her?

Luckily, in the pamphlet, she gives all of us an out. (phew) Towards the front of the pamphlet in outlining its purpose it says,

“The value of projections is to support policy makers to BOTH better prepare for the future and to act where policy change could lead to better outcomes”.

Page 5

The pamphlet therefore argues that we should EITHER prepare for the outcomes that it suggests (an increase in the number of people with a major illness by a third) or to make policy changes to lead to better outcomes.

I choose the latter.

Regular readers of my blog will recognise that since the new year my posts have been exploring not just the what needs to change in the NHS but the how it needs to change. I hope I have not given the impression that any of these changes are easy. But I also hope I have made it clear that they are possible. My time span for these changes has been the decade up to 2035.

This pamphlet rolls this end point forward for a further 5 years to 2040.

So, my assumption is NOT that everything in the NHS plan 2025 will work, but that some things will, and they will have an impact by 2040.

The main issue the pamphlet warns us about is the increase in the number of people who will have major illnesses by 2040. Most of those with major illness are classed with having multiple long-term conditions or long-term conditions with exacerbations.

Below I outline three different interventions. Regular readers will recognise them.

On a general point the page 5 quote above talks about policy changes.  Readers will recognise that the issue is not to have these three issues as policy (they have been policy for quite a while) it is putting them into practice.

      1. Social and economic interventions to increase healthy life years at a national and local level – delaying the onset of long-term conditions amongst the poor by a few years.

Last July I posted about the Covenant for Health. This argues how national and local practical interventions can have an impact. They recognise that tackling obesity for example, will need not only a nationally coordinated programme of health in all policies but will need to actively involve most of civil society. Obesity is not inevitable. The extent to which existed 30 years ago shows it wasn’t inevitable then and it’s not inevitable for the next 15 years.

      1. NHS interventions to reduce the move from minor to major illness. The NHS will work with patients and civil society to better manage long term conditions and avoid making the move from minor to major illness.

Readers will recognise that I not only agree with the demographic fears behind this pamphlet. I would go further and say that if the NHS cannot play a bigger role in reducing the extent to which minor illnesses become major illnesses, then it is difficult to see how the NHS survives to 2040.  If we stick to the current model of care, the numbers of NHS clinicians that will be needed to treat this extra third of people with major illness will finish that model off. People often talk about an existential threat; this is what one looks like.

Better secondary prevention, much better mix of clinical and other skills, a financial system that prioritises prevention and a public narrative that explains how much better that will be for the public will all be necessary to bring about this change in practice. Policy in this area will just not be enough. For the NHS to thrive there will have to be millions of parts of new practice.

      1. The application of moderately old technology to the better development of health and health care work with the public

A few weeks ago, I posted about the necessity of improving the use of technology in the interface between the NHS and the public. The point I made then is that most of this technology has been around for a while and we use it frequently the rest of our lives. That’s why here I deliberately don’t use the word NEW to describe the technology, its moderately old technology that would revolutionise how the NHS and patients interact about care. One of the main reasons that minor illnesses become major illnesses is the difficulty of monitoring the minor illness. Technology can enable much more monitoring to be carried out much more regularly and the results can be communicated to NHS organisations.

None of this will be easy, but we can do it.