The NHS in 2030 - A People-Powered and Knowledge-Powered Health System
The NHS in 2030 - A People-Powered and Knowledge-Powered Health System
The NHS in 2030 - A People-Powered and Knowledge-Powered Health System
in 2030
A VISION OF A PEOPLE-POWERED,
KNOWLEDGE-POWERED HEALTH SYSTEM
Jessica Bland, Halima Khan, John Loder,
Tom Symons and Stian Westlake
JULY
2015
ACKNOWLEDGEMENTS
This paper was written by Jessica Bland,
Halima Khan, John Loder, Tom Symons and
Stian Westlake.
Many thanks to: Lydia Nicholas for helping
write and develop the stories; Jullie Tran
Graham for helping with some of the initial
research for Sections 3 and 4; Helen Kay
and Sir John Chisholm for their help with
information on Precision Medicine, as well
Kevin Fong
www.nesta.org.uk
Nesta 2015
The NHS
in 2030
A VISION OF A PEOPLE-POWERED,
KNOWLEDGE-POWERED HEALTH SYSTEM
CONTENTS
EXECUTIVE SUMMARY
1. PRECISION MEDICINE
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36
CONCLUSION 46
EXECUTIVE SUMMARY
This report offers a vision for the NHS in the mediumterm future.
Most discussions of the future of the NHS have at most a fiveyear horizon. They generally
begin with a familiar and foreboding list of challenges. An older population with more
longterm illnesses and increasing expectations will be expensive to look after. Healthcare
productivity has stagnated and further efficiency savings are hard to find. Drug costs are
rising. Public funding for health is under more pressure than ever.
These are all serious challenges for the near future. But the longer term, specifically the run
up to 2030, could offer more hope. The NHS has the opportunity to take advantage of two
powerful and underexploited sources of innovation that have the potential to make care
better and, under the right circumstances, cheaper. These are the rapidly accelerating pace of
digital technology, and the power of social innovation.
The report explores how these two trends could make the NHS and the wider health system
better. It focuses on four specific changes. Two developments involve harnessing the power of
knowledge to improve care.
1. Improvements in digital technologies enable, on the one hand, an explosion in the use of
personalised medicine, underpinned by genomics.
2. New digital technologies also allow people to track and analyse their own health data, and
to share this and other health knowledge with others in ways that will aid prevention and
management of longterm illnesses.
Two developments making better use of the power of people.
3. Social innovation is the key to a revolution in how people are involved in their own care
and that of others, improving the quality of care.
4. New insights into human behaviour will improve clinical quality and make it easier for
people to lead healthy lifestyles.
This is not to say that there will not be other innovations in healthcare in the coming 15
years: medical science will of course advance, new drugs and devices will be developed, and
management practices will evolve. Any future strategy for the health service will need to make
the most of these too. It will also need to address headon issues like the relationship between
how services are designed and inequalities in the health of the UK population. Tackling public
health issues like obesity will need sustained engagement with the food and drink industry
and new approaches to regulation.
This report concentrates on opportunities that Nesta can see coming into focus through our
programmes, research and partnerships. Even so, nothing about the future is certain; these
innovations have much to prove if they are to have the positive effect on healthcare that we
hope they will challenges that we explore later in the report.
Despite these uncertainties, we believe that people power and knowledge power have an
unusually important contribution to make to healthcare in the UK in the coming 15 years. It
is one that is sometimes neglected in ongoing debate over the NHS of the future. There are
champions for both among health service leaders, pioneering practitioners and a burgeoning
community of digital health entrepreneurs. But the potential of people and knowledge power
has not yet been absorbed into mainstream media and political debates about healthcare.
The future that this report focuses on may seem far off. Fifteen years extends well beyond the
current NHS Five Year Forward View, and for that matter beyond the lives of this and the next
Parliament. But preparing for a radically different future requires us to start now. The time to
think about the potential of knowledge, power and people power is now. Making the most of
people power and knowledge power will require longterm changes in practices, attitudes and
behaviours; investments will take time to pay off. If these investments are not made, there is
the risk that the NHS will become increasingly unsustainable, even if its nearterm challenges
are mitigated.
We hope this report, and the possible future that it envisages, will encourage this investment
to happen now, rather than postponing until it is too late.
Of course, information and citizen action have always had a role to play in healthcare, albeit
a supporting one. Selfcare has long been recognised in terms of remembering to take
medicine or managing physical fitness. At least two transformational health movements
hospices and first aid were social innovations then coopted by official health systems. The
NHS has sought to incorporate expert patients into its models of care since the 2000s. On the
information side, data on the geography of a cholera outbreak in 1854 led to one of the first
local authority public health interventions. The NHS patient number system means that the
UK can make decisions about improvement to healthcare based on some of the most detailed
health statistics in the world from morbidity to prescribing data.
But the immense and growing power of digital technology and the renaissance of social
innovation suggest that both these trends have much more to offer. This paper is an attempt
to imagine what the health system might look like in 15 years time, if these innovations are
fully adopted and the NHS reconfigured around them.
Why 2030?
In an age of strained budgets and regular crises, thinking about what happens in 15 years time
may seem frivolous. But when major technological changes are afoot, it is often impossible to
understand them without lifting your eyes at least briefly to the horizon.
Thinking freely about the faroff future helps identify changes that may not be urgent today,
but could be the beginning of something important. This is not a matter of predicting the
most likely advancements. Useful futures projects think creatively about the kinds of services
that could be developed based on trends, technologies and movements visible today.
By 2030, precise and rich information about patients means that medical
researchers better understand how complex factors interact at an individual
level. A stronger data infrastructure linking doctors and researchers means that
genetic and other biological data, as well as daytoday behavioural data, is part
of decisionmaking in the clinic. (Section 1)
People will have much greater opportunity to help themselves and others
achieve a healthy life. They will be better supported by the NHS to do this.
Healthcare professionals will work with people to identify emotional and practical
support as well as clinical treatments. Volunteers and nonclinical staff will
support people to maintain healthy behaviours and access more than medicine
services such as peer support networks. Millions of people will be mobilised to
volunteer in the community and formal health services. (Section 3)
Policymakers will need to take seriously the design of health interventions and
treatment, as a powerful influence on the uptake of healthy behaviours. Through
understanding behavioural insights, the design of many things from city centres
to medicine packaging will go with the grain of the rest of peoples lives.
Healthcare will not take place in isolation, but via a flexible set of services that
makes it easy for people to live healthy lives. This may include making it easier
for people to undertake exercise and eat well. Health professionals will be better
at tailoring treatment and intervention in response to a patients lifestyle and
changing condition. (Section 4)
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1. PRECISION MEDICINE
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2030 LANDSCAPE
By 2030, healthcare benefits from more precise knowledge about how genes affect different
individuals physiology. Detailed data sets on human genetic information (genomics) are
complemented by phenomics: data on phenotypes including human proteins, hormones
and metabolic processes. These are combined with ubiquitous monitoring devices and
sophisticated data analysis technology. Large investments in precision medicine came with
heavy R&D costs. More monitoring technology initially meant more diagnoses. Together these
initially increased the cost of treatment the UK population. But the gamble paid off. Now, it is
possible to quickly and accurately diagnose a condition, and create a treatment plan tailored
to the individual using a new generation of decisionsupport tools. The benefits for precision
care are now felt in cost terms as well as clinical ones.
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SIGNALS OF CHANGE
Todays medical knowledge is based on the average response to a particular treatment.
However, drugs and other therapies do not have identical impacts on everyone; there is wide
variation in response, and many people have no response at all. Individual variation in biology
and behaviour has a role in explaining these differences. The way that these factors are
manifested in the human body is complex and still not well understood.
There are programmes gathering and interpreting the data needed to develop precise
medicine. The 100,000 Genome Project is perhaps the most well developed example
sophisticated whole genome sequencing and well developed data collection and
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management. There are increasingly accessible tests for molecular data about humans or
infectious disease. These might provide the first widelyused precise diagnostics. There will
also be new forms of patient data collection and smarter ways to move data around the
health system.
Genomicallyprecise medicine
The UK is home to a trailblazing project offering whole genome sequencing for 100,000
individuals where more knowledge about their genome could lead to better treatment for
a rare disease or cancer. The pilot for the project has had a few early successes, diagnosing
some conditions that can be treated. Its predecessor, Deciphering Developmental Disorders,
sequenced part of the genome in over 8,000 children, finding 12 new genes that contributed
to rare diseases. Its not clear whether the rationale for whole genome sequencing goes
beyond those with rare diseases and specific cancers. But the infrastructure created by the
100,000 Genome Project is a valuable first step towards a national healthcare system that is
capable of delivering precise, personalised treatment.
There are a number of proofofconcept examples of the gains that come from more
genomically precise medicine. Oncotype DX tests predict a patients benefit from
chemotherapy as well as her risk of breast cancer recurrence. They can reduce chemotherapy
use by 20 to 35 per cent and avoid costs of $4,359 per patient per year. This is a net saving of
$384 annually taking into account the cost of the test. Widespread whole genome sequencing
would likely pick up many more relationships between genes and responses to cancer drugs.
Increased knowledge about the genetic basis of developmental disorders should lead to more
preventative treatments.
The cost of Oncotype DX tests is restricting take up in the UK. Technology improvements are
needed to make these treatments more financially viable. There are promising steps forward.
Whole Genome Sequencing at scale as part of the 100,000 Genome Project costs less per
person than one Oncotype DX test.
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Machine learning is a group of computing techniques that may be able to discover new
signals of illness or monitor the effects of treatment. It requires huge volumes of data to be
effective. It is already employed to automate the analysis and diagnosis of medical images.
Radiological images are analysed to find features without a doctor there to supervise or direct
it. These techniques applied to information from wearable technology could provide a step
change in the fine grained information we have about human behaviour and health.
Nesta has developed the idea of digital health communities, as a way to describe new kind
of emerging intermediary in this area. Through the Centre for Social Action, Nesta and the
Cabinet Office have funded uMotifs Big PD project. This is a data driven community for
those with Parkinsons Disease (PD). Drugs to control the symptoms of Parkinsons wear off
in hours, vary in their effects unpredictably from person to person, and become less effective
through repeated use. The 20 minutes per year that patients spend with a consultant is rarely
enough to get this medication right. Big PD aims to use accelerometer and other data to
track body movements, and give early warning signs of medication wearing off. Clinicians,
and often patients themselves, will be able to medicate much more accurately. This data will
also be useful for research and early diagnosis. PD is often present for up to ten years before
diagnosis. This is what the ultimate data sharing system, centred on a new digital health
community, might look like.
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Patient
Wearables
Clinician
Data Analysis
Wearables
Smart phones
Big PD
Data
Knowledge
Research
Request
Research
Community
Smart consent
There is range of new tools designing consent systems that are more attuned to peoples
concerns about how their medical data is used in research. This includes dynamic consent:
where participants use a web interface to consent to specific research using their data, and
where they can reverse that decision. The 10,000 Personal Genome Project, run through UCL
in the UK, offers an online course, in order to ensure informed consent. All participants have
to take this before having their genome sequenced. The UKs BioBank process for providing
biological samples includes oneonone consultations before participants give consent. This
is an expensive and timeconsuming process. Changes to the European data protection
legislation will affect consent for data used in research. This will be most disruptive if it
requires consent for each research project rather than blanket consent for researchers to use
individuals information in their research.
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2030 LANDSCAPE
By 2030, sensor technology will be everywhere. Monitoring changes in biological health and
behaviour is easy and cheap. Most people use devices that pick up these signals to monitor
their own health. The NHS and employers have responded to incorporate these trends into
how they provide for health and wellbeing. This data can be easily integrated with existing
clinical data.
Smartphones and wearables came first. But soon technology companies were producing
portable versions of more complex monitoring systems: air quality monitors, EEG brain
sensors and molecular testing kit to find out whether an infection is bacterial or viral. This
pervasive data collection allows people to perform new kind of constant, mobile health checks
on themselves. Its akin to the dashboard, gauges and alarm signals in a car today, making it
easier for patients and their doctors to track what is happening with their bodies.
Most acute care centre appointments are made automatically. When patients arrive at a clinic
all of the detailed data about them will have been analysed ready to help diagnose them.
These early warning systems have reduced the cost of acute care, particularly for conditions
that can be managed through preventative measures. Pharmacists and local health services
help people interpret the data they have collected about themselves, referring them to
specialists when appropriate. This is vital at a time when most healthcare spending is on
managing longterm conditions, which require close monitoring that can now be done outside
the formal health service.
There was public concern when portable monitoring technologies first became available.
After this period, enforcement of privacy laws increased and a fast growing section of
the population demanded easy routes to sharing their data with each other, doctors and
researchers. People accept that the advantages of data shared under these conditions greatly
outweighs the potential risks.
For some, monitoring technology is part of everyday decisionmaking. They manage their
own care, experiment on themselves, monitor the effect of lifestyle changes and take part in
massive online patient data collection exercises to inform medical research and national policy
decisions. Something like an expanded version of the NHS Citizen platform provides online
discussion platforms. The National Institute for Health Research has programmes to support
patientled research, including managing peer review and developing it into national learning
resources.
Others are less interested, but are happy to sign up for whole genome sequencing and regular
physical checkups. Some are more wary of how data about them could be used by doctors
and researchers. They maximise their privacy settings on the national digital patient portal.
People in the UK in 2030 will use a digital patient portal for other interactions with the health
service too: appointment bookings and contacting specialists and viewing test results. There
will be a hugely expanded digital NHS Choices, including 111Online options for immediate
advice from doctors. This and other platforms provide routes into research: experiments in
service delivery, advice on how to work with medical technology researchers or take part in
largescale clinical trials.
Public Health England has partnered with media organisations and behavioural insights
experts inside the NHS (see Section 4) to provide schemes for people to better manage their
own health, which reach 97 per cent of the population.
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This system is different from the current frontier of digital health online appointment
booking systems and medical records. It is like peertopeer finance compared to an online
bank account or eBay rather than a simple online shop. The health knowledge commons
offers everyone the chance to integrate their own information and preferences with the health
service they receive. They monitor themselves, choose the services they use and support
those groups and individuals that want to create new kinds of healthcare.
SIGNALS OF CHANGE
There are initiatives today that illuminate the plausible direction of change.
Wearables
There is a new generation of consumer technologies that we wear all the time from
heartbeat monitors to materials that can sense haptic skin response. These are now stretching
out into small sensor technology, including pills with ingestible sensors in them.
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MEDICAL
SERVICES
New intermediaries
PatientsLikeMe
give to research
Medical
treatment
centre
Longterm
care support
HealthBank
strictly private
da
ta
al
gn
si
PERSONAL
.BIO DOMAIN
Digital social
activity
DataCoup
sell to companies
Genetic
data
Google
glucose-measuring
contact lens
Samsung smart
watch measuring
physical activity
Cambridge
Cognition
app testing
cognitive
function
Sensoria smart
socks analysing
foot movement
mental
concentration
gait
activity
level
Neurosky
Mindwave
EEG
Proteus
ingestible
sensor in
medication
and wireless
monitor
Sensum
haptic
skin sensor
measuring
alertness
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Patient communities
Patient organisations are increasingly spaces of innovation. The novelty of their approach
lies in the use of their experiential and clinical knowledge to make themselves part of the
networks of experts on their condition. These groups do not want to be relegated to the role
of fund raisers and passive providers of data but are increasingly engaged in the process of
producing and circulating knowledge that is critical to their condition. The AKU Society in the
UK recently used crowdfunding to finance a clinical trial into the rare disease their members
suffer from. They also have an active online forum and clinical partners.
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rewards of their vegetable plot, laying out a healthy feast as part of a street party. Colin invites
another volunteer who assisted his wife whenever she was discharged from hospital after her
surgeries; she is impressed and relieved to see how active he has been since the bereavement.
Colin used to resent trips to the primary care clinic each visit marked an occasion when his
pain medication failed. But he recently started helping other older people use the personal
health portal in the clinics preparation area. His enthusiasm for wearables and data resonates
with the other older clients more than younger volunteers have in the past. He has more
patience with their mobility challenges. From his wifes last years, he empathises with many
peoples difficulties managing their own health and medication while mainly focused on a
partners care. One person he helped then convinced him to join her at an exercise session
designed for people with arthritic joints. The specialist sessions have really helped his pain.
2030 LANDSCAPE
In 2030, most people feel in control of their health and know there is support to help keep
them healthy whether thats managing a specific health condition or just doing more
exercise. When clinicians diagnose someone with a major health condition, they also connect
them to other people with the same condition to get emotional and practical support at a
critical time.
It is routine for health coaches and service navigators to work alongside clinicians and
patients to enable people to choose and control the social and medical support they need
to live as well as possible. Nonclinical professionals are now integrated within health service
teams to create a bridge of support between the clinical world and life at home.
More widely, local communities donate their time and skills to health services. Volunteers
are often motivated by their own positive care experiences and good will towards the
NHS. Others have ambitions to work in health themselves. Volunteers are trained and given
structured roles that complement paid healthcare professionals. Exhealth professionals are
on call to volunteer in overstretched health services at times of high pressure, such as in
winter months.
Beyond formal health services, there are many more ways to support other people. Dayto
day acts of kindness build vibrant and strong neighbourhoods and they also directly improve
health and wellbeing for the giver and the receiver. Older and previously isolated neighbours
are better supported and more able to live independently for longer.
The NHS has become a network that routinely works with volunteers, carers, voluntary sector
organisations and social enterprises alongside traditional NHS roles. Healthcare is understood
to happen as much in local community groups and between neighbours on the same street, as
in hospitals.
The shift has radically changed the relationship between professional, patient, and society:
Helping ourselves. People are supported to look after themselves better and be in control
of their health. Clinicians work with patients to develop individual health goals and connect
them to services that give people the skills, knowledge and confidence to live better with
health conditions. Those who are less active in their own health receive dedicated support,
such as from a peer coach or social sector broker.
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Section 2 points towards the range of channels people would have to communicate with the
NHS in 2030, such as digital patient portals or health monitoring systems that feed data into
the NHS. But it is the interaction with professionals in the NHS that represents one of the
most fundamental changes. More collaborative conversations between people and healthcare
professionals shift power towards the patient, creating more peoplepowered and person
centred care.
Consultations are now structured to encourage and support patients to be active participants
in their own health. The waiting room has been remodelled as a preparation area, where
individuals can log into their personal health portal, which displays their most recent test
results with explanations, asks them to upload their recent wearables data to be considered
in the consultation and has guides on how to set an agenda for a consultation. When the
consultation starts, the patient and doctor agree a joint agenda focused on goals that are
important to the person. The care planning process then establishes the combination of
clinical and social interventions that will help them achieve these. Afterwards there is the
opportunity to debrief with a health service volunteer, reflect on the consultation and arrange
any additional support such as a health coach or care navigator. Local and online peer
support communities are suggested using the expanded NHS Citizen platform, along with
other resources from medical research charities and patient organisations. With thanks to
Adrian Sieff at the Health Foundation for his input in developing this scenario.
Health volunteers tangibly improve the experience and care provided in hospital, clinics
and other formal health settings. They are involved in every stage of a patient journey. In
hospital and clinical settings, volunteers perform new roles that are now seen as essential.
They provide a combination of pastoral and practical care for patients and help people to use
digital technologies. They accompany them before and after operations, help people to use
new assistive health devices and organise selfmanagement plans.
Outside of formal health services, volunteers and nonclinical paid staff support people
to take control of improving their health, such as losing weight or doing more exercise,
or to make new friends in their own neighbourhood. Expert patients and carers play a
semiprofessional role as coaches, therapists and leaders of groups with similar medical
experiences or care needs, alongside voluntary or social enterprise sector professionals or
clinicians. This adds a new dimension to healthcare by creating networks of volunteers and
nonclinical professionals that support people to take control of their health, maintain healthy
behaviours and stay on top of their health conditions on a daytoday basis.
Many neighbourhoods now have networks of first aid responders who can attend to some
emergencies before ambulances, and can deal with some situations which do not require
hospitalisation. It is normal to participate in schemes like Shared Lives Plus, providing family
based care and support for people who would otherwise be in specialist health and care
settings. There are tailored volunteer packages to enable people to settle well at home after
an extended stay in hospital, where transition is foreseen as potentially difficult.
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This level of volunteer and nonclinical support requires interventions that are backed by
robust business cases and ways to attribute positive outcomes to specific changes. Health
service procurement leaders have redefined their role in response. They now actively support
local partnerships of charities, social enterprises and userled organisations. They aim to
actively develop the market of volunteer and nonclinical support to respond to local needs.
Funding is designed to follow local activity and funding entitlements are used to make
financing this support easier. Commissioning uses many different legal and reward structures,
such as alliance contracts that bring together multiple providers who share risk and reward
and work towards a single set of shared outcomes. Contracts are increasingly based on
producing specific, agreed outcomes.
People helping themselves, one another and health services represents a set of new social
movements for health: changing the basics of how the health system approaches the
prevention and management of health, in particular longterm conditions. The impact for the
NHS is improved care, better outcomes and lower costs:
Practical care and support that prevents exacerbations and hospital admissions and
accelerates discharge.
Reduced isolation and loneliness, strongly linked with ill health and high healthcare usage.
Fewer, but more effective, clinical visits and consultations.
Improved patient experience and care while in hospital and other health settings.
People have improved confidence, mood and wellbeing which positively reinforces overall
health.
There is a golden thread of patient confidence, capability and motivation that makes many
of these changes work. So with People Powered Health must come with a more granular
understanding of what motivates people to become active in their health. Section 4 describes
services that make the most of human behaviour amplifying the effects of more people
involved in health services and more people managing their own health.
SIGNALS OF CHANGE
A people powered NHS is a health and care system that is for people, by people and with
people. Nestas PeoplePowered Health programme (201113) supported six schemes that
bring power to the patient and the community, supported by clinicians. The programme
involved five types of practice:
More than medicine. Nonclinical support that gives people the skills, knowledge and
confidence to improve their health and wellbeing, such as health coaching.
People helping people. Peer support that gives people emotional and practical support to live
well with longterm conditions; this can be online or offline, in groups or onetoone.
Redefining consultations. Clinical consultations that are genuine partnerships between
professionals and people, focusing on peoples goals and prescribing both clinical and more
than medicine support to enable them to achieve these goals.
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Networks and partnerships. Statutory and social sectors harness their combined knowledge
and expertise to commission, design and deliver holistic and integrated healthcare services
focused on what people need to improve their health.
User codesign and codelivery. A health system driven by the people within it, not by the
institutions that provide care, requires deep engagement by people using services in all
stages, from design and delivery to evaluating the service.
These and other forms of personcentred care have demonstrated benefits for a health
system. The Business Case for People Powered Health estimated a 7 per cent reduction
in the commissioning budget if these approaches were put into practice at scale, through
decreasing A&E attendances, reducing hospital admissions, reduced length of stay and
decreased patient attendances. The Realising the Value programme, recently commissioned
by NHS England, will outline the health value, financial value and wider social value in care
that gives people and the community more control.
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Since then, providers have found it easier to respond to Colins individual needs, given his
complex conditions. It is rare that they do not have all the information that they need to treat
Colin. There are few datasharing glitches because the system has been designed over several
iterations with local providers.
Colin always has appointments scheduled after lunch. Recent research carried out in three
NHS Trusts found that people like him were best able to take on board new information in this
time slot. They based this profile on the medicines he takes and his health conditions. Colin
completes a short feedback questionnaire after appointments to allow the NHS to monitor
whether these findings are consistent with his individual case.
2030 LANDSCAPE
The NHS in 2030 has benefited from a commitment to understanding the factors that
influence human decisionmaking and behaviour. At the beginning of the 21st century,
the biggest users of behavioural science were private sector businesses like supermarkets
and internet businesses, who used insights from psychology, data collection and rapid
experimentation to understand their customers and make more money. But in 2030, the
NHS is now considered to be a global leader in its use of behavioural insights. It uses them
to reduce clinical errors, to target programmes better, to make treatments more effective, to
improve patient engagement and to promote the healthy activities which prevent illhealth.
In 2030, far fewer things go wrong in hospital and in doctors surgeries. This is not primarily
because people are smarter, but because the system is better designed to reduce the
likelihood of mistakes. The process of diagnosis and prescription will be enhanced by access
to greater data resources and analysis than an individual doctor can keep hold of. But this
means they will need sophisticated decision-support tools to help them make the most of
these digital resources.
Clinicians make decisions based on prompts and supports which anticipate natural human
biases or the presence of fatigue and stress. Medical information from the results of blood
tests to scans to monitoring completed in the home is more saliently presented, based on
rigorous testing of design templates, language, colours and visuals. Technology functions as a
reliable failsafe, making the use of faulty heuristics unnecessary and freeing clinicians to focus
holistically on the individual case in front of them.
The equipment, medical settings and technology of 2030 make it easier for the right
decisions to be made. These refinements include new simplified decisionmaking guides
which use a short selection of Yes/No questions to support primary care decisions. These
filter essential information, anticipate a decisionmakers likely biases and provide them with
risk and prevalence information that is simple and easy to digest. Information about cost and
peernorms are also routinely presented when ordering tests and prescriptions to encourage
the appropriate use of resources.
Wearable technologies alert doctors to their risk of decision fatigue in the same way that a
sports coach today can be alerted to a sportsmans risk of physical fatigue in real time during
games. New technology enables doctors to be prompted when there are factors which might
be adversely affecting their decisionmaking, such as the time elapsed since they last had a
break, the number of decisions they have made that day, or number of patients consulted.
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The use of behavioural insights is governed by consent from the public. Public discussion
forums for behavioural insights have been set up online using the new digital platforms
mentioned in Section 3 to agree the terms on which government and health authorities
can responsibly pursue behavioural change initiatives. This provides the public complete
transparency about plans to test and use behavioural insights, and the ability to raise
concerns about these plans. A deliberative discussion is used to explore these concerns, and
in some instances the public can stop the testing of behavioural insights.
SIGNALS OF CHANGE
Behavioural science has been used successfully by private sector companies for decades, and
is now an increasingly common tool in public policymaking. For governments it is the aim for
policymaking to be informed by the likely impact that policy decisions will have on human
choices and behaviours. It seeks to understand the wide variety of influences on behaviour
and decisionmaking and patterns of healthpromoting or harming behaviours. It then aims
to use this knowledge to inform the design of environments, products and systems that make
it easier for us to make healthier choices.
There is huge potential for the health sector. Many people eat unhealthily, drink too much
alcohol, smoke cigarettes and dont exercise enough behaviours that are set to exert
increasing pressure on the health system. Through behavioural insights we are beginning
to understand how this can be tackled. Our decisionmaking is heavily influenced by
various mental shortcuts, such as being loss averse or focussing only on experiences of the
present moment, whilst failing to take longterm costs and benefits into account. Often
these shortcuts are helpful enabling efficient decisionmaking in the face of multiple
considerations but at other times they can lead to choices which are harmful to our health.
Behavioural insights can inform various actions to make healthy behaviours more likely
by changing the architecture of choice, through the careful design of incentives and
disincentives, reinforcing positive social norms or reducing the friction we experience
in forming healthy habits. Research has already found some powerful insights about the
influences on decisions and behaviour in a health context:
Commitment Devices. Signing a symbolic contract has been shown to increase success in
performing a regular physical activity.
Decision Fatigue. The cumulative effect of making repeated care decisions increases the
likelihood that primary care clinicians prescribe unnecessary antibiotics for acute respiratory
infections. This offers an opportunity to create an intervention which makes antibiotic
prescription when tired impossible.
The Cabinet Office report Applying Behavioural Insights to Health provides more examples:
Defaults. Including a prompted choice of organ donation on application forms for driving
licenses increased the percentage of people signed up to donate organs from 38 per cent to
60 per cent in Illinois.
Visual Prompts. A supermarket chain in New Mexico, USA increased the amount of fruit and
vegetables its customers purchased (without affecting profits) by creating a visual prompt in
its trolleys which marked out one section for fruit and vegetables.
30
Incentives. The Step2Get Initiative which combined an interactive game, swipe card
technology and a reward scheme increased the number of children who walked to school by
18 per cent.
Reciprocity. Schemes which offer reciprocity for time spent volunteering to deliver social care
have been found to be successful in different contexts. Japan was one of the first countries to
test this model and now has over 400 local schemes. A pilot of the scheme in a London local
authority found it increased volunteering and delivered a positive costbenefit ratio.
At present, the use of behavioural insights is considered a relatively niche and discretionary
activity. Public Health England and the Department of Health have dedicated behavioural
insights teams, but outside of these central bodies behavioural insights are relatively
underused. Yet encouraging healthy behaviour is one of the most cost effective things a
Government can do. Moreover, there are behavioural aspects to almost everything the NHS
does, from the daily work of professionals through to the organisational decisions taken in
commissioning groups, arms length bodies, regulators and in the Department of Health.
This approach is not a replacement for other governmental levers, such as legislation,
regulation and taxation. Instead, behavioural insights complement these levers. They can be
used to make other approaches more effective, or to evaluate them for effectiveness and
unintended consequences.
Behavioural insights are a good fit for supporting innovation in the health service. They can be
cheap to implement, manageable for existing staff to adopt, measureable using existing data
sets, scalable and provide immediate pragmatic improvements to services.
31
It is not just NHS users but also the staff that might experience a very different health
system by 2030. The institutional layout and ways of working could be fundamentally
different. People are doing much more to look after themselves. They come into the clinic
with more knowledge about their own condition and a stronger idea of what they need
from a health service. This chapter draws on some of the changes in Sections 14, imagining
more fully what this means for the kinds of jobs, information infrastructure and institutional
arrangement of the health service in 2030.
32
2030 Institutions
The NHS estate looks different in 2030, with fewer large facilities and more smaller
community settings. The move towards People Powered Health and community based
care has finally reached a scale at which some big hospitals can reduce in size, and district
hospitals have closed altogether, or been reconfigured as community health resources where
a range of clinical and nonclinical groups support communities to live healthier lives. There
are more polyclinics, and health professionals are increasingly colocated with other public
services, creating more accessible health services. This diversity in primary care is supported
by common data infrastructure. This set of standards and protocols for data analysis and
storage is shared with pharmacies, which manage patient monitoring data.
33
So far this paper has described an optimistic vision of the opportunities created by 2030
health service where knowledge and people power are starting to have a positive impact.
But there are challenges that could trip up these opportunities along the way.
34
35
activation scores and are less likely to engage with People Powered Health.
36
Medical research leaders in the UK have called for a new social contract for medical
innovation, where greater attention is paid to the public interpretation of medical knowledge,
and delivers services sensitive to how much individuals want to know about their biological
and genetic status. It is one where patients own goals, preferences and actions are valued.
This will require new kinds of interactions between health service and individuals, designed to
reflect the diverse ways people want to interact with those services.
37
The interactions between professionals and patients heavily influences how everyone thinks
about their own role in healthcare. Shifting the emphasis of these interactions towards
collaborative care planning requires changes in the way doctors and nurses are trained
and supervised. And it is an opportunity to rethink conceptions of selfcare, expanding it
to include activities currently in the domain of professionals with expert knowledge. This
transition has already begun in some areas, such as the Ryhov Hospital in Jnkping, Sweden,
where patients are trained to administer their own kidney dialysis. In England, targets for
numbers of patient care plans have distracted some healthcare professionals from the reason
for care planning it is a tool for doctors and patients to make decisions together.
This approach could be extended by piloting of new approaches to consultations and
selfcare: flipped consultations, where tests and symptom checks are done outside of the
consultation room and appointments are used to actively plan care; group consultations,
in which there is one clinician and several patients with the same longterm condition in an
active learning environment; or expanding Health Checks to Life and Wellbeing Checks to
take account of wider determinants of health including social factors.
One way of supporting patients engagement with doctors is to provide access to their own
data more easily, or move data into services they want to use. This could include a better
system for accessing the GP API, which apps for appointment booking or offering new care
services could be built on.
Clinical decisions today are based on parcels of data, not continuous monitoring. Data from
new monitoring technologies runs the risk of creating a rift between patient and physician
if their perceptions of data legitimacy differ. To mitigate this risk, other intermediaries in the
healthcare system could take on a larger role, offering access to and consultation on the
output of monitoring devices.
38
This campaignbased approach could be extended to a more permanent function that helps
structure health knowledge from outside the current research and clinical system so that it
is useful inside that system. This might include direct support for patient organisations already
trying to do this. This could be a way to deliver part of proposal A.
Trials based on behavioural insights must be built on shared values for what is ethical and
in the public interest . To do this, there should be transparency about what is happening:
from the design of experimentation through to dissemination of results and diffusion of
new approaches. It needs to be clear to any member of the public looking at the use of
behavioural insights in health that experimentation is not being treated as an end in itself. This
could be addressed by a government advisory committee responsible for overseeing health
service experimentation that has positions for citizen representatives.
39
Interventions that increase selfcare and nonclinical support are usually complex and
difficult to replicate faithfully. There needs to be a new highprofile organisation to generate
more evidence, starting from strong foundations: academic credibility, sustained funding,
diverse expertise and a clear mandate. The Coalition Government signalled its commitment
to life sciences research with the cuttingedge Francis Crick Institute. There should be the
same commitment to People Powered Health. It is important that the institute can quickly
demonstrate value and build momentum.
Government should seedfund a partnership of academic, charitable and government
institutions undertaking groundbreaking research and development into patient and
community participation in health and care. The institute should support design of new care
pathways focused on prevention and with a significant role for community engagement. This
could be a way to deliver proposal C.
The Institute would provide a highbenchmark for evidencegathering. Through standard
templates, it could aggregate and analyse programme evaluations. It should invest in models
that translate large quantities of research and evaluation data into information to support
service commissioning or care planning.
Mobilising volunteers
A national brand would add status and recognition to the value created by highimpact
volunteering. But any new organisation would have to avoid a onesizefitsall approach,
responding carefully to what motivates people to volunteer in health often a passion to
40
support local people and services in their local area. A national campaign would create a
lighttouch way to bring together schemes such as Kings College Hospital Volunteers and
the St. John Ambulance and Community First Responders, so that citizens willing to give time
know where to find opportunities.
To mobilise a new generation of volunteers, there also needs to be new kinds of opportunities.
This means more digital technologies like the Good SAM app that links registered first
aiders with people who need emergency help. There also needs to be more highimpact
opportunities for volunteering, such as reserve support for services and emergency response.
The roles must be drawn up to complement those of paid professionals, adding additional,
measurable value that is important to patients and carers.
41
42
For people working in institutions, ways of working are encoded in information systems.
Implementing a change in workflow typically requires changing information systems. This
means changing the configuration of software. So the easier it is to do this, the better. At
present, frontline staff do not find it easy to make changes. Information flows are baked into
the initial design of systems or are only changed during occasional formal reorganisations.
Cambridge University Hospitals NHS Foundation Trusts new eHealth system came with
training for more than 100 of the Trusts staff, qualifying them to adapt the software
themselves. This may still be a fairly inflexible process, but it is a move in the right direction.
Often there is little expectation that frontline staff want data beyond average treatments
times and patient responses. Getting access to data beyond these aggregate results is
possible, but time consuming. Analytics teams should be available to NHS staff, helping them
find and use the data most relevant to their work and to any changes they want to make.
These should come with interfaces for staff to access data, which need to be as simple and
intuitive as those on a smartphone.
43
Research institutions often have stronger overseas networks than integration with the health
service. More and more medical research will be based on the individual rather extrapolation
from clinical trials. This means that research needs to be more embedded in the national
system that provides that kind of access to patients.
The 100,000 Genome Project has put in place a strong loop between clinical and research
community that leads from a patient providing a sample through to treatment. It runs through
a new protocol for data collection, diagnosis and treatment.
Consent
and sample
collection
Treatment
DNA
extraction
Validation
Feedback
to clinician
Clinical data
Interpretation
Biorepository
Sequencing
Variant
calling
A whole genome sequence needs to be compared to other peoples in order to call out its
specific variants. This is then combined with details about the patients full physical condition.
Researchers then examine this profile of the patients in order to send an interpretation
back to doctors. It remains the doctors responsibility to decide on a formal diagnosis and
treatment.
44
This kind of protocol should be embedded further inside healthcare. Some efforts already
exist. New NHS Genomic Medicine Centres are recruiting patients, taking samples and
providing consultations for the 100,000 Genome Project. They extend to tests beyond whole
genome sequencing; a series of molecular pathology nodes in the UK will bring biomarker
research closer to clinical practice: working with the research base, pathology and genetic
services and industry.
Industry partnership will support the translation of this research into treatment.
Biopharmaceutical companies in the GENE Consortium each contribute 250,000 and
at least one fulltime employee to the 100,000 Genome Project, in return for access to
genome sequences and relevant clinical data. They have encouraged the formation of Clinical
Interpretation Partnerships involving more than 2,500 clinicians and scientists focusing on
specific diseases or crosscutting themes. As precision medicine progresses, there needs to
be a more diffuse research and analysis centres, including partnerships with industry, that
close the loop between clinical and research settings.
Genomics England, the body set up to deliver the 100,000 project, is the gatekeeper for
the new standards and systems for data sharing. This creates a single point of access for
researchers and standard forms for data, which mean results are useful to the global research
community. The cost of sequencing was reduced tenfold by using a single supplier.
A central authority overseeing precision medicine will be vital for building the research
infrastructure, including standard formats for data and access to patient records. It will also
coordinate access to developments in underpinning technology like new sequencing kit or
data analysis tools. This could be a way to deliver proposal D.
45
46
CONCLUSION
The changes to healthcare imagined in this paper would add up to a fundamental shift in
how people understand health and who is responsible for managing it. By 2030, there may
be new kinds of knowledge, new ways of using it and new kinds of people involved in health
support and services.
There will be many other profound changes that affect the health service. But these are the
ones that Nesta can see coming into focus, through our funding programmes, our research
and our partnerships.
The way to these largescale changes is obscured by uncertainties. Not only are the effects
of other shifts in the health system impossible to predict. There are also serious challenges
in designing successful knowledge and peoplepowered systems. The pace and direction
of change in technology and attitudes to health are hard to forecast. Digital platforms that
enable new kinds of collective health intelligence may never emerge. The assumption that
there is an unexploited appetite for health volunteering might just be wrong. Its difficult to
see a single structure of institutes and initiatives that would be futureproofed against this
range of possibilities.
And there is another reason why understanding how to respond to these opportunities is
difficult. They are not the same in nature to historical options for health reform. Reforming
the social contract between and health service will require policy and support mechanisms
that can respond to the changing rules of engagement. This is not about restructuring the
traditional institutions of healthcare. It is about a setting up today the cogs and gears for a set
of new functions that support healthcare in its broadest sense. These could include:
47
These are not big initiatives compared to the scale of the UKs health enterprise; they are
suggestions for how to lay the groundwork for a strategic shift that harnesses the value of
people and knowledge power.
Nesta will take on some of these challenges. We will work in partnership to make change
happen. As an organisation, we already fund projects, generate research and lead
programmes that focus on the value of knowledge and people in healthcare. In the future, we
will build on this to better understand and champion the systemic changes they lead to. Our
ambition is to become a hub for restless innovation and critical debate. We want to challenge
the institutions and norms of the health service, making sure that those that exist in 2030 are
fit for purpose and not accidents of history.
48
Nesta
1 Plough Place
London EC4A 1DE
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@nesta_uk
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www.nesta.org.uk
July 2015
Nesta is a registered charity in England and Wales with company number 7706036 and charity number 1144091.
Registered as a charity in Scotland number SCO42833. Registered office: 1 Plough Place, London, EC4A 1DE.