By Julia Bainbridge, Partner and Head of Health, freuds
We live in interesting times: technology is transforming our lives in ways we never anticipated but now accept as normal. We take for granted that we can order food with an app, turn on the heating before we get home, move money around without visiting the bank, and watch whatever entertainment we want, whenever we want on whichever device we have at hand.
Health is no exception: we can already count our steps, track our units, use a chatbot to help us quit smoking or ask Alexa how to breastfeed. Apple is embedding the technology to detect atrial fibrillation (abnormal heartbeat) into its watches[i]. Who would have predicted that the internet of things would one day include a wearable electrocardiogram?
But the big benefits to population health will come from innovations that are prescribed not purchased. The heavier users of health systems are not technology enthusiasts, who tend to be wealthier and healthier, but the laggards, who tend to be poorer and unhealthier. This has implications for how new technologies will be paid for: the case has been clearly made that public money invested in prevention has the potential to generate huge dividends[ii]; the problem is that those dividends will mostly be paid to future, not current, administrations.
To maximise benefits, health services will need to think and work creatively and collaboratively with technology providers, data specialists, pharmaceutical companies and others on solutions to the bigger health problems.
Why are we so unhealthy?
In the developed world, we have become used to rising life expectancy, the elimination of many diseases, vaccination against others, cheaper medicines, breath-taking medical advances…and yet, we are spending more and more of our lives in poor health: why?
When the NHS was founded, medical need was a rare and sporadic event. It was set up to treat acute health. Bar a few chronic case patients (tellingly called “invalids”), most people were healthy for the majority of their, admittedly much shorter, lives. If they needed medical attention it was because they caught something contagious, ingested something poisonous, got into a fight or had an accident. If they didn’t immediately die, the role of the health service was rescue and repair: rush them to a hospital, give them medicine or perform surgery and then get them back out into the world, cured.
Not anymore. In England today, 7 million people are living with heart or circulatory disease, 5 million with diabetes, 18 million have musculoskeletal conditions such as arthritis – all chronic, progressive, incurable conditions. Mental health conditions are also on the rise: 3 million of us have a diagnosis of depression (many more are undiagnosed), nearly a million have dementia. Much of this is preventable. However, as public health tackles one risk factor, others emerge. Smoking, previously the most significant and modifiable driver of non-communicable disease, is now a niche pursuit. New threats, such as obesity and loneliness, have taken its place. As a result, long term conditions are now so common that most (58%) people over 60 have at least one[iii], and 2.9 million people have three or more[iv]. Treatment and care for people with long-term conditions is estimated to take up around £7 in every £10 of total health and social care expenditure[v].
In a few generations, disease has moved from being an occasional, brief event to a constant reality for a large proportion of the population. With more and more of us sick, for more and more of our lives, the shift in healthcare has been from “getting well” to “living well”. And that’s where technology can help. Indeed it has to help. Because we cannot hospitalise half the population. We cannot even provide a weekly face-to-face consultation or daily home care for that many. A 2018 report by the Royal Free Charity found even patients with chronic disease spend less than 0.1% of their time with a medical professional[vi].
“With more and more of us sick, for more and more of our lives, the shift in healthcare has been from ‘getting well’ to ‘living well’. And that’s where technology can help.”
So what can technology do?
The first thing technology can do is predict, with increasing accuracy, who is likely to get sick and with what. As more is learned about how different diseases arise, and it becomes possible to access each patient’s DNA, we can use polygenic risk scores to assess an individual’s risk and target preventative interventions.
The second is to provide earlier diagnosis. This matters. In general, the sooner a disease is detected the better the outcome for the patient will be. However, relying on patients to spot the signs and symptoms of disease is a limited strategy. Many diseases do not have noticeable symptoms until they are already well advanced. That is one of the reasons why, in England today, one in five cancers are still diagnosed in the emergency room[vii]. Our current technologies cannot always solve this: a person can live with lung cancer for several years before the tumour reaches the size at which it would show up on a chest X-ray. Yet the detection of circulating free tumour DNA in peripheral blood may provide opportunities to detect cancer mutations early in patients harbouring the earliest stages.
The third is to provide personalised medicine. As possible treatments multiply and each patient has more conditions, there is no one-size-fits-all drug. We need a bespoke drug regime for each patient that uses information about their unique DNA and anticipates the interactions between medicines to prescribe the best option for them.
The fourth is to monitor, with greater precision, the progress of disease, so that adverse events can be anticipated and averted. This is where the virtual assistant may be joined by the virtual clinician. The Royal Free Charity has written a compelling case for a future in which AI will make it possible to embed monitoring in people’s daily lives, automatically alerting healthcare professionals or triggering interventions as needed. This technology has the potential to transform the lives of people living with heart and circulatory disease, predicting the likelihood of strokes and heart attacks[viii].
And finally, for those of us who do want to do everything we can to stay healthy, technology will provide us with a nudges to maximise our wellbeing, informed by passively collected information about our bodies, our behaviours and our environment.
Where will the solutions come from?
Health systems are not geared up to deliver these solutions alone. They tend to be risk-averse and slow to change, often for good reason. To generate the scale of change and innovation required, we will need new collaborations between technology and healthcare, between the public, private and third sector and between patients and clinicians. The upfront investment will be considerable.
We are already beginning to see interesting partnerships across sectors, including recent press reports of a $300 million deal between the consumer DNA sampling start-up 23andMe and GlaxoSmithKline, to develop the potential for personalised and more effective drugs[ix].
If the pace of technological change elsewhere is any indicator, we can predict that treatments and services that are currently small scale and high cost will rapidly become mass and cheap.
Will anyone really want this?
All of this presupposes a public that is increasingly empowered and engaged in their health. But if people are to accept a more active role in the management of their health and wellbeing, they will need to understand more about how these different technologies work, interrelate, and benefit them personally.
8 out of 10 adults freely admit to doing at least one thing every day that they know will damage their health. Will a population adept at ignoring a real doctor listen any more closely to the virtual version? Will the trade-off between the humanity of a face-to-face consultation be compensated for by the convenience of an app?
The good news is that we appear to want this change. Research published by Roche found that 63% of Generation Z would be comfortable receiving a medical diagnosis from a chatbot and 56% would be comfortable speaking to a chatbot about their mental health[x]. 85% of all adults are comfortable with the NHS using an app and 89% are comfortable sharing their data with the NHS[xi].
Perhaps we will one look back on the days of queues in the GP surgery and the agonising wait for test results with the same amazement that we now look back on scratched vinyl and payphones.
[ii] British Medical Association (2018) Prevention not Cure: securing long-term sustainability of the NHS
[iii] The Kings Fund (2018) Long Term Conditions and Multi-morbidity
[vi] Royal Free Charity (2018) Beyond the Fog: a future for public healthcare
[vii] Ellis-Brookes, L (2017) Routes to Diagnosis, NCRAS, London
[viii] Royal Free Charity (2018) Beyond the Fog: a future for public healthcare
[ix] Weber, L and Backs A (2018) Want to know the tech trends of 2021? Follow the Money, Campaign, London
[x] Roche (2018) The NHS at 100: future-proofing healthcare, London