As the NHS begins its journey to embed the aims and objectives of the Long Term Plan, it is important that the principles of population health are not lost, say James Roach and Jeremy Hooper
The NHS Long Term Plan is underpinned by the idea that improving population health will deliver benefits now and into the future. There is plenty of evidence that improving population health can deliver value for everyone, while offering overall benefits for individuals as well.
The Office for National Statistics (ONS) and the Marmot Review have both recently noted that life expectancy at birth has begun to stagnate. These reports focus on socioeconomic inequalities, which remain high; people living in areas of relatively high deprivation have a shorter life expectancy and healthy life expectancy than those living in areas of less relative deprivation. However, intergenerational inequalities also need to be addressed if we are to help the NHS on its path to sustainability.
Currently, the NHS and most OECD countries focus on high risk patients, who individually use a significant proportion of healthcare resources, including clinician time and money, not to mention the burden it places on individuals managing their conditions. It’s been predicted that by 2021, approximately 20% of the population (those aged 65 and over) will use almost half (42%) of the NHS budget. If we can shift the focus from short term symptom management of these high risk individuals, to improving the entire risk profile of the population through longer term strategies aimed at preventing illness and promoting health of low and medium risk subgroups, then we can build a truly population health focused health and care system. This is not a new concept—it is an approach to promoting population health that was proposed by Geoffrey Rose more than 30 years ago.
According to the ONS, estimates show that there are around 32 500 000 people (58% of the population) aged 20 to 64, and there are around 12 200 000 people (18% of the population) who are aged 65 and over. Our current approach to healthcare focuses on caring for the small proportion of the population with the greatest risk of poor health outcomes and reducing this risk, but this approach is not sustainable. We need to help a greater proportion of the population avoid the use of acute healthcare and reduce risk for the entire population.
The Health Profile for England shows the positive benefits the current approach to healthcare is having for older populations. Looking at morbidity as measured by years lived with a disability (YLD), we see a reduction for those aged up to around 30, while for all those older than 30 there has been an increase. However, those increases in YLD are greatest in those aged 45 to 59 where the increase is around 7%, while for those aged over 70 the increase is around 4% (see figure 3 in Chapter 3). This is further reflected in data looking at self-reported health status metrics (see Additional Data in Chapter 3). For those aged 25 to 54 there is a small increasing trend in the proportion reporting fair to very bad health, while for those aged 75 and over there is a definite downward trend. This potentially has consequences for individuals and their families but also wider consequences for society. Addressing these intergenerational inequalities in outcomes alongside our country’s socioeconomic inequalities will help the health and care system within England achieve sustainability.
There are many reasons for these trends and they can only be tackled by acknowledging the many determinants of health. The evidence on population health shows that addressing social factors (for example, housing, access to nutritious food, and education) related to health can promote health, prevent or reverse morbidity, and reduce the burden on health services now and in the future.
As the NHS begins its journey to embed the aims and objectives of the Long Term Plan, it is important that the principles of population health are not lost. Health and care systems have an important role in supporting health and resilience in all ages, but promoting it in those of working age will help to keep the population healthy now and into the future, reducing the burden of disease and demand for healthcare services. This requires a shift from current biomedical care delivery models, which are too reliant on drugs and hospitals, to ones which embrace different ways of supporting and promoting health and resilience, working with people and communities around local priorities.
This shift will not happen immediately and nor should it. There are no off the shelf solutions that will sustainably solve these problems across different contexts. It will take time and concerted efforts to design/re-design, develop/re-develop, and deliver approaches that can sustainably promote health and resilience.
Early identification of disease and social prescribing give us the roadmap to help us on this journey, but scaling up these approaches will require that we as communities (local, national, and international, and across sectors) come together to learn from and share with each other. Only by doing this can we benefit from our collective experiences and ensure that health and resilience are an inevitable by-product of living life. If we are to make a real success of the NHS Long Term Plan and prevent ill health, we have to develop a new healthcare offer for working age adults and put the solution for long term healthy lives in their hands.
James Roach is managing director of Conclusio Limited, a clinical service transformation consultancy. He was previously the programme director for integrated care at NHS West Essex Clinical Commissioning Group (CCG) and has also been a CCG CEO and chief operating officer and joint director across health and care settings.
He will be taking up a new role in the NHS in January 2021 focusing on the development of integrated care systems. As managing director of Conclusio, he has led a number of national transformation programmes, launched several national reports, and has brokered and led partnership initiatives across the NHS and the pharmaceutical industry.
Competing interests: Nothing further to declare.
Jeremy Hooper is a health economics and intelligence consultant at Conclusio Limited. He has worked on the analysis of large and complex data sets in the defence and health sectors for over 25 years, supporting a number of public sector organisations to understand their performance and how that can be used to improve outcomes for the organisation and patients.
Competing interests: Nothing further to declare.