The Future Vision for Healthy Ageing
How can we develop and progress a future vision for healthy ageing which incorporates all stakeholders? This is an enormous challenge since all of us struggle to incorporate long-term thinking into what we do, when we are faced with daily (seemingly more urgent) short-term problems. Who better to discuss this topic as part of PCL Health’s Healthy Ageing series, than Andy Wilkins, the Founder of Future of Health who joined us for our 20th June discussion on Clubhouse.
Andy presents and consults on a wide range of human-centred topics including re-thinking health and care for the 21st Century, value creation and re-thinking policy and strategy in a customer experience age. He recently published a major report for the NHS and Policy makers on the Digitisation of Healthcare and how it can enable the introduction of a new 21st century era of more systemic and person-centred healthcare.
Throughout his career, Andy has mostly been involved in the idea of customer-centred innovation. He tries to think about innovation not from the technology up but starting from the point of view of human beings looking out towards the product and service. His work has tried to understand what value looks like from a customer perspective. To give just a few examples, he has worked on patient experience studies for The Royal Free hospital in London and has also done studies where he has spent time with mental health and diabetic patients to understand their unmet needs and where the opportunity for introducing technology lies. Below is a summary of some of his key comments and the ensuing discussion points raised at the event.
Why is healthy ageing so important?
One of the reasons why this topic of healthy ageing is such an important topic is the sustainability of our healthcare systems. Our economies are tightly coupled to this question because across all Western populations we have an ageing population and the demographic balance is changing as we’re getting older. We are seeing more and more chronic disease. People over 50 often have more than two chronic diseases with all the associated comorbidities. Those are diseases that stay with you for life, creating more and more complications. So, as well as an ageing population, we have more disease within the ageing population. And we have more treatments and solutions — whether it’s pharmaceutical or digital health technologies. When you add all those things up, what you get is a cost curve that is trending upwards by 4–5% a year in terms of cost inflation here in Europe. In every major system this is not only a burden for individuals faced with disease but a burden for the economy more broadly.
One of the interesting things about looking at how we do healthcare at the moment is that most of our healthcare systems actually don’t focus on health. Instead, they are really ‘sickness engines’ which react to people being sick with chronic diseases. Reactively supporting people and reactively treating people is just an attempt to manage chronic disease and keep it at bay for as long as possible (or at least slow down the rate of decline). It’s not a cure. So, in ageing populations we have two challenges — how do we do this better, how do we treat people and help them to look after themselves better but also how do we take a step back and think about why health in our society is so compromised, among so many people? When we look at that question, we get into topics like health behaviours and obesity and other structural issues that drive poor health outcomes. The principal reason that we have early mortality is, in fact, nothing to do with the quality of healthcare. It’s the social determinants that really drive health outcomes. And these are disproportionately high in disadvantaged areas. So, if you’re taking a big picture view, the systemic challenges around health in populations requires more systemic thinking.
Let’s zoom in on chronic disease because there are rich opportunities for improvement there. The current model of healthcare has typically been one where the patient goes to the doctor, either because there’s a problem or they have routine appointments with regards to an existing condition or if there’s an escalation of a problem. This ‘patient goes to the doctor’ model where healthcare revolves around the convenience of the system rather than the patient has been the dominant force for 200 years.
How has Covid changed the way we look at healthcare?
Covid has forced us to really rethink that model and ask how we take healthcare to the person, rather than the person having to come to the healthcare. Aside from the current need for social distancing, why is that important ?
Kaiser Permanente and a whole bunch of others have conducted time and motion studies which show that those with chronic disease spend less than 0.01% of their time in the presence of a healthcare professional, and 99.99% of their time on their own. We know that over 40% of people do not take their medication properly for chronic diseases in general and that people aren’t looking after themselves very well. In addition to mental health issues and/or poor behaviours, there is an acceleration in the decline of people because we’re not able to support them properly. 99.99% of the time, this is where health is won or lost. That is the golden area for digital health to take health out of the clinic and make it ever-present with people, helping them in those moments and within their own specific context — whether it’s self medication or whether it’s looking after yourself better and improving your daily habits.
The advent of Covid-19 has forced us to think about remote care and there have been many really interesting examples of virtual wards, which is essentially using digital health tools to remotely monitor patients’ Covid status or oxygen saturation. There is a huge amount of interest now that we’ve proven what new technologies can already do. Now there is an opportunity to use emerging technologies to see how we can support patients in real-time and continuously, whether it be diabetics or people with heart disease or any range of complications that can be supported remotely. This enables us to spot what’s going on rather than waiting for people to fall into crisis. This is already an opening up of a whole new vista of possibility around ‘always-on’ care.
What is the role of healthcare data in healthy ageing?
Delivering ‘always on’ care brings in, of course, the role of data including looking at trend data, which starts to change the nature of the medical relationship with the patient. If you can see what’s going on with someone 24/7, then some really interesting questions open up around who is liable and responsible when stuff starts to go wrong.
We stand at the dawn of the greatest changes in medicine and technology. As well as new forms of digital technology to support people, there are new insights coming along, for example, around the genome, which will allow us to personalise our health and wellbeing. We need to bring these issues to the attention of policymakers and healthcare system workers emphasising that the quality and depth of how we can support people will become greater if we can see the bigger picture.
The other side of that coin is that, if this information is being used to support people in managing and supporting their own health, we need to reduce fragmentation. Having a situation where someone has added 15 or 20 apps for different parts of their body or different facets or fragments of their health, is not really a sustainable long-term picture.
So in order to help people to help themselves to take more agency and control of their health, we need to think about how this information can be brought together in more holistic ways to help individuals with the opportunity of understanding and managing more aspects of their health. We have a great convergence of social trends and technology changes, which brings with it the need to think more systematically about this whole challenge.
Do you have any particular technology in mind that could completely reshape the way we look at healthy ageing?
There are certainly technologies around diagnostics. That’s one area to watch. Being able to measure things that we currently either find difficult to measure or cannot measure is opening up a whole new round of possibilities. We’re already seeing this with wearables e.g. the work that Apple’s doing on the Apple Watch (and others in the market like PCL Health) so we are increasingly able to measure things like oxygen saturation, blood sugar is probably coming along, blood pressure, heart rate. These physiological markers that point to or represent some state of health or illness are very useful. Some technologies further down the road that are coming will enable us to start to use mass spectroscopy, by using light to shine through the skin. You get a refracted pattern back to show some of the more complex molecules in our blood, such as different proteins, etc.
There’s also digital health improvements. Being able to track steps, what we eat, our stress or mental state of mind, these are all other areas where digital health technologies and digital therapeutics are appearing. Digital technology extends and deepens the opportunities for care and self care.
What about the downsides of aggregating this data? How can policymakers face the challenges brought by aggregators of digital data?
Well, it’s probably just worth recapping the benefits of aggregating the data. As I mentioned, one of the benefits is in thinking about health as not just a bunch of diseases but actually to see the body as a complex adaptive system with DNA providing the deep source code, if you like, for how our cells and our bodies function.Our body is very good at keeping itself in some form of homeostasis at all these different levels. And it’s only when the body starts to receive stressors that take it out of its comfort range, in a way that causes damage, that we start to see these pathological cascades that then pop up as symptoms that we then call ‘diseases’- whether it’s diabetes or heart disease or dementia. So, the ability to measure more of these things and to understand what’s going on and see that as a whole, gives us a picture of what’s going on with that person’s health. If we see it as an emerging system, there’s value in that.
There’s also value in the healthcare systems themselves being able to see where people are in their journey, what can we do, and when should we step in to support them and to be much more proactive rather than reactive. If you abstract it up to another level we can start to see how effective our healthcare systems are in supporting populations with these mixes of health conditions and status, and then rapidly, right up to the national level, we see the overall health of our population. What are the factors at play, what could we do from a policy level to start to have real impact with different cohorts of people living in different contexts? So data is valuable in itself but also in what you’re pointing to, in its ability to lay bare and make more transparent many additional things about our health.
Now what about the issue of data privacy — who owns this data, who gets to see it on and on what basis is it shared? This is a really important question and something we’ve been drawing to the attention of policymakers because this journey of ever greater data of the most personal kind is such that, if there is a misstep, the whole country could turn against this. We need to be able to trust what happens with the data.
Step by step as more data becomes available, it’s so important to engage the population in a conversation around what is happening — what is this data, what does it mean and what are the issues around sharing it — so that people are involved in how this unfolds. Ultimately, the data needs to be owned by the person: it’s their data, it’s their body, it’s their health. And at the moment in the UK, for example, your health information record is owned by the Secretary of State, it’s not even owned by you. So there’s a big journey to go on as data expands and explodes and there are huge questions to be asked about how that data journey unfolds in the coming years.
Why do you see person-centred health care as so important to the future of health?
I’ll start with the biggest possible level and then drill down. If you go back hundreds and hundreds of years, the sense of what constituted health and good living was seen as something holistic — living in harmony with others, living in harmony with the world, living in harmony with yourself. So this idea of balance, harmony and wholeness, has been with us for quite some time. From the scientific revolution onwards, however, what we’ve had is a way of seeing the world that seeks to break things down to see how they work, which has been incredibly powerful and useful.
When it comes to health, we’ve had huge scientific breakthroughs that break down the body’s organs into their functions, right the way down into microbiology. What’s arisen out of that is that we’ve got all these experts in parts of the body — different ‘ologists’ for almost every organ. But what we’re seeing now — in this era of a rapidly ageing population where we have much older people living with these chronic conditions — is that the older and sicker you get, there are more silos and the patient has more and more people involved in their health. So we get this situation, almost like a factory-level production health system with all these silos, looking after bits of your health or bits of your body. And as people get older and sicker they’re having to wrap themselves around ever more of these silos.
Multiple studies have shown that people get more and more confused, they spend an increasing amount of time involved in healthcare situations that are very fragmented and disjointed. If we are looking to really improve people’s health, we need to start to galvanise a shared understanding across these silos. We need to start moving to a world where we start to wrap healthcare around the individual. Healthcare professionals need to know how to act in concert with others and help individuals have more agency and control over their own health. That’s a big picture outline of why person-centred health is so important at the moment to policymakers.
In the US people are starting to outline more of a vision for virtual care, do you see the same thing happening in other countries?
What we’re seeing is a general recognition that we need to look beyond single treatment views of patients towards seeing things more holistically. There’s lots of work on diabetes, for example, which shows that it’s not just about glucose monitoring and insulin, it’s also about diet and exercise, and other lifestyle factors that are core to being able to support people looking after themselves and keep on top of their diabetes. Around 40% of all diabetics end up in depression. Depression, of course, reduces your will to look after yourself so that then contributes to a continuing downward spiral. But no one ever treats a diabetic for depression, until they fall into a crisis. That’s just giving one example, in microcosm, to show why, if we’re interested in the health of people, we need to start thinking not just about the treatment side, but about lifestyle and living with a condition, which brings in the need for a broader suite of services that can be pulled together to address that.
What we’ve learned from other industries, especially in the digital world, is that there is a huge opportunity, instead of thinking about single solutions to start thinking about platform thinking. How can we bring into being the digital infrastructure to support one or two particular use cases but then leverage that platform to be able to extend it out to support other related or adjacent issues? And I think what we’ll see in the digital health space is a move towards more platform-based approaches which will start to build out a richer suite of services beyond that which we see today. It will definitely start with the easiest ones to offer.
What we’re likely to start to see is the greater use of wearables or remote diagnostics to monitor people in real time, remotely. The US is quite advanced in this with places like the Mayo Clinic in Cleveland who have built a remote diagnostics AI based platform, which they’re using to monitor patients with a range of different conditions but also monitor people holistically who have more than one condition. They are then using that AI insight to provide the opportunity to see trends, to see analysis and to become proactive. The new model is about ‘leaning in’ to provide support, rather than just reacting to a crisis. That’s a really interesting development.
One under-explored area is how you can use these technologies to support people and enable them to get the maximum quality of life with any particular condition. There are huge opportunities there — both revenue opportunities but also a way to think about how we might mobilise technology in support of individual and collective well being.
Individuals are interested in their own data because they’re interested in themselves. When they see that data, they want to be more proactive in how they manage their health and that means a better quality of life for all of us. If we can truly understand ourselves, then we can potentially adapt ourselves because until we really know our own habits and behaviours, we can’t really change them. What flows from that is also a much greater granularity of data that we can then use for medical research or for policymaking or for lots of other aspects of healthcare. And that’s where blockchain can come in with the potential to first own our own health data and have our data held securely but then also to create these kinds of data marketplaces where that data can be securely shared, monetised and even traded.
What are the big mega trends that we’re going to see in healthcare in the next 10 to 15 years?
Some of the big trends include: genomics, personalised medicine, new diagnostics and greater use of machine learning and AI and robotics. Let’s look at those 10 to 15 year trends, let’s imagine all of those trends have played out, they’ve all landed at scale. What might be the end game and what might be the vision for the long-term future of healthcare?
Having a long term vision opens up a space for different organisations to come together to say, how can we combine what we’re doing to deliver something even more holistic and compelling? In the future will we transcend just looking at our own interest and look at some collective bigger picture that we could all work towards?
Certainly in the UK, that’s a vision that’s starting to get some traction now and policymakers and healthcare system leaders are thinking about creating systemic structures that bring these pieces together, in support of trying to reach for that long term vision. We know full well that the journey there will have many steps and that many innovations that need to be brought to bear but at least knowing the direction of travel makes the whole long term future a little clearer.
We tend to think about most things in life in a piecemeal way and focus on incremental change rather than major step changes in innovation. What does a revolutionary vision for the future of health look like to you?
Doing my recent research has been really interesting because it got trying to imagine what the future would look like if we had unlimited data — what would we do with it, and how would we structure that? The only conclusion one could draw when thinking about that was that if we had all that data, what it essentially allows us to do — and which some industries are starting to do in their own fields now — is the idea of creating a digital twin. What that means is to start to build a simulation of a person. So we can start to see everything that is going on from DNA to physiological status down to the microbiological level and to simulate what’s going on on a person’s health. This is pretty much the only way that you could really take all that information and start to make sense of it, by creating a digital double.
Imagine if we can start to run simulations on people’s housing or look at what happens if we change this medication and whether the person will be able to undertake certain behaviours if we provide them with this kind of support. So we get to look at what might be the unfolding story of someone’s health. This ‘digital double’ starts to have the possibility of becoming a digital health coach.This AI-driven coach can see everything that’s going on in your body and has access to the best possible knowledge, to give you the best possible advice customised to you on what’s going on or what you might want to do in the future. This will drive much more informed decision-making and more collaborative care.
In this vision, we have a three pillar model of empowered individuals, digital health coaches playing the role of supporting people, and then sharing data with a healthcare system that is much more joined up. In fact, now that new digital healthcare system also could extend its boundaries to share the insight and knowledge with other actors who are not currently in healthcare. So we’re talking about, maybe, local governments, Social Services, charity or community groups, and possibly even bringing in food companies to be part of the solution now, rather than part of the problem, by providing personalised nutrition.
The healthcare system of the future might include a constellation of bigger actors or a broader set of actors, all working on a more common and shared understanding of the truth, for individuals. I think that heralds a really really exciting potential future for systemic healthcare driven by technology.
Join us in the Healthy Ageing Room for our next event on Clubhouse on 10 June at 5.30pm GMT where we will be examining ‘Healthy Ageing, Dementia and the role of technology’ with Dr Samir Shah: https://www.joinclubhouse.com/event/PD5rv5pa
If you’d like to see a glimpse of the future and request a demo of PCL Health’s remote monitoring platform, contact us to book a time.
For more about Andy Wilkins, find his profile on Linked in.
