The future of health care is often conceptualised in terms of improved treatments emerging from the bio-medical science base – for instance increasing the precision with which particular therapies can be targeted. Many of these advances in the effectiveness of care will have supply side consequences in terms of cost and some will require service re-configuration – regenerative medicine and bed-side diagnostics, for example. However the larger challenges are likely to originate from increased demand. The service will have to adapt to these supply and demand side changes. This blog considers the role of applied research in informing these adaptations in order to improve the overall effectiveness and efficiency of services.
We discern three trends which, absent a major perturbation such as international conflict, will alter demand over the medium to long term. The time horizon for our analysis is the next quarter century, given that the longer the time horizon the wider the variance in any predictions.
The trends are as follows:
- The population demographic will continue towards higher proportions of elderly people.
- The dependency ratio (ratio of working age to young and retired people) will become increasingly adverse.
- Demand for services per capita will increase.
None of these assumptions is unarguable as they involve outcomes that have not yet been observed. They are ordered from least to most contentious.
- That the population will continue to age is almost a given, but the rate at which it will do is less certain. Some predict that over a third of children alive now will reach a century. However, the rate of increase in life expectancy may slow as the large reductions in smoking related deaths are absorbed into the base-line. Immigration could affect population projections in ways that are hard to predict. The recent sudden increase in mortality among white middle-aged males in the USA, but improvement in survival of low socio-economic group children in the same country, shows how difficult projections can be. A recent demonstration of trends over two decades suggests that age-specific prevalence of dementias are reducing, arguably because risk factors for cardiovascular disease are also risk factors for dementia. This will not reduce the total prevalence of dementia, of course, if life expectancy continues to increase. 
- The worsening of the dependency ratio is almost a corollary of an ageing society, but again the extent to which this happens is less certain as the work force gradually internalises the notion that 65 years of age is not a biological watershed but a social convention. But delayed retirement will not solve the problem of a deteriorating dependency ratio; absent a method to delay ageing, many types of work, such as aviation and mining, are simply not suitable for older people. In addition, as people work longer at the end of life; so policies are encouraging longer leaves of absence from work outside the home to care for young children. So, all things considered, the dependency ratio will become more adverse as a function of increased longevity. Note, Britain appears to be at an earlier stage in this transition than many other high-income countries, such as Japan and Germany, and the opportunity for immigration to mitigate the tendency is likely to be accentuated given recent events.
- Demand for services contingent on an ageing population is somewhat controversial. A reasonable planning assumption is that people will be healthier at a given age but this will not completely mitigate the frailty of older people at a given age. In that case we must assume a rise in demand as the population ages, even if age-specific morbidity declines to some extent.
Implications for the NHS flow from the above. Demand for services will increase relative to resources. That is to say there will be more old people relative to working age people and there will be more frail people relative to the population and demand will outpace economic growth. All of this may be compounded by a tendency for old people to live in remote areas at a distance from major conurbations where health services are concentrated. However, this problem will be less acute than in most other countries.
There are many possible mitigations and the NIHR has a role in all of them; these are listed in the table below.
Factors to help the service cope with increasing demand.
| Mitigating factor
||How it might work
|Major technical advances that might affect demand.
||A ‘cure’ or prevention for dementia would both improve the economy (and hence supply) while supressing demand.
||Probably lies outside our 25 year time horizon. Will prolong life and hence increase the proportion of frail elderly people.
||Potentially very high but out of scope. Medical advances more generally likely to increase demand by increasing longevity.
||An ‘extreme’ form of skill substitution.
||Unlike other mitigations there is an extensive research literature. Beneficial for capable patients minimal impact on global demand.
||The correct answer to improving care, reducing demand will require development of interventions and further research.
||Can make care safer and supply more efficient.
||Full electronic notes disrupt patient communication in their current form. A lot more needs to be learned about the design and implementation of this deceptively complex technology.
||Huge benefits in prospect but the socio-technical aspects require extensive development and research.
||May substitute for expensive/scarce human resources.
||Humans require the care and attention of other humans.
||Moderate. Likely to assist rather than replace clinical input.
||Less expensive staff (physician’s assistants) substitute for more expensive (doctors). Increasingly feasible as health care increasingly codified.
||Limited by the complexity of decision making in patients with many diseases.
||Very hard to say without more research. May be modest.
|Pro-active community services
||Prevent deterioration to improve health and decrease admissions.
||Existing research disappointing – may actually increase demand by identifying self- correcting illness.
||Potentially great but we are in the foothills of discovery.
Mitigating demand is not easy in the face of the demographic factors mentioned above. It is often argued, even in official enquiries, that prevention is the key to reducing demand. While prevention may reduce demand arising from particular diseases, such as diabetes, survivors go on to develop further diseases on their trajectory to death. It is therefore not at all clear that prevention will reduce total demand and it may even be the case that deferred demand is augmented demand. There are some potential mitigating possibilities. A prevention or cure for Alzheimer’s disease would make a massive difference. Less distant is an ‘artificial pancreas’ that might massively simplify diabetes care. Methods to make people independent, such as home telemetry, have had nugatory impact on demand to date, but this may change in the future. Patient self-care is beneficial in improving healthcare and satisfaction, but effects on total demand have been modest.
If supply side measures might help services cope with the consequences and demand continues to rise, then two points should be noticed. First, efficiency gains are notoriously difficult to achieve in service industries. Second, the likely increasingly adverse dependency ratio is likely to limit expansion in skilled staff. Partial solutions may lie in manufacturing, including robotics and information technology. Skill substitution is a future area where it may be possible to improve efficiency. In particular, physicians assistants may reduce costs overall. The research for skills or system substitution is not entirely positive – for example, substituting nurses for doctors may not improve efficiency because consultation times had to increase. There is an international trend to provide more care at ‘grass roots’ by means of Community Health Workers (CHWs) – an area where high-income countries are learning from low- and middle-income countries. CHWs have a large potential role in improving care – helping patients to adhere to medications, providing preventative services, identifying deteriorating patients. Their effect on reducing demand is less certain, and on occasion they may actually increase it.
Readers may think that the CLAHRC WM Director can be rather pessimistic, even nihilistic. Not so, CLAHRC WM has recently conducted an overview (umbrella review) across 50 systematic reviews of different methods to integrate care across hospitals and communities. Discharge planning with post-discharge support is highly effective. Multi-skill teams are much more effective if they include hospital outreach than if they are entirely community-based. Self-management is effective but mainly for single diseases. Case management is of minimal value. Across all intervention types, length of stay was reduced in over half, emergency admissions were reduced in half, and readmissions were reduced in nearly half. In almost no case did the intervention make any of the above outcomes worse. Costs to the service were reduced in over a third of intervention types, but the quality of evidence is poor on this point – a topic that is being addressed across all CLAHRCs. And here is the CLAHRC WM Director’s point; there are no quick wins and no silver bullets. And the solutions are not self-evident. Only by patiently trying out new things and evaluating them methodologically can things improve. It may sound self-serving, but that does not mean it is incorrect – CLAHRCs have an immense contribution to make to improve the effectiveness and cost-effectiveness of health services.
— Richard Lilford, CLAHRC WM Director
I acknowledge advice from Prof Peter Jones (University of Cambridge), Director of CLAHRC East of England, but the views expressed are entirely my own.
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