At the centre of this month’s 10 Year Health Plan for England are two explicit political concerns. The first is the spectre of a middle-class opt-out from the NHS, leading to a loss of electoral support for a tax-funded health service for all. The second is that without change, the health care system will eat into an ever-increasing share of our economic output, crowding out other things we might want to do with our private and collective resources, including investing in welfare and public services beyond health.
The plan’s response to the first of these concerns (redolent as an impetus behind the “choice” reforms of the mid-2000s) is to up the ‘retail offer’ made by the NHS to the patient-as-consumer: to match the ‘on-demand’ nature of much of our modern consumption experience with an approximation of its health care equivalent. This offer includes direct access to blood tests and specialists, a doctor-in-our-pocket providing two-way communication with virtual and sometimes real clinicians, and tailored pre-emptive health care via genomics and wearables. It might all sound great, were it not for that second concern: that our seemingly insatiable desire for more and more health care is fiscally unsustainable.
However, the great hopes – or, in the language of the plan, “bets” – are that pre-emptive health care and empowered patients will not just save money (through detecting disease early or avoiding it altogether), but that the very means through which that will be done – technology, data, medical science – will itself grow the economy, entailing that cake may be had, eaten, and slices of it left to feed other appetites.
Enlarging the cake
This hope – to “transform the NHS into an engine for economic growth rather than simply a beneficiary of it” – is explicit throughout the plan and moves far beyond the familiar rhetorical coupling of the NHS to economic growth via a fit and healthy workforce.
As the penultimate chapter in the plan puts it:
“On growth, health research and innovation has become a global ‘race to the top’. Nearly every country in the world is grappling with the health consequences of an ageing population and a rise in chronic illness. The countries that provide the best solutions will reap substantial economic benefit from exports, private investment and the high-productivity jobs associated with the life sciences sector. That is why the life sciences are so central to this plan, which has been developed in tandem and full alignment with the Life Science Sector Plan and the UK’s Modern Industrial Strategy.”
The somewhat-delayed Life Science Sector Plan has now finally been published, and has been written against a backdrop of fraught negotiations between the government and the pharmaceutical industry over the latter’s demand – backed by President Trump – for the NHS to pay significantly more for new branded medicines. Industry’s opening gambit in those negotiations has reportedly been a £2.5 billion increase in the NHS drug bill – potentially wiping out more than a third of the real-terms increase in NHS funding next year – and has been issued alongside threats to pull manufacturing plants and investment out of the UK.
The global race to the top?
It is therefore perhaps not surprising that chapter eight of the 10 Year Plan is in effect an investment brochure directed at the pharmaceutical and med-tech industries, highlighting the benefits the NHS already brings manufacturers and developers beyond the headline prices it pays, and setting out a vision of an even more conducive operating environment in the future.
These “huge advantages” include “unrivalled, representative population data” – relatively unsullied by the data gaps and distortions created by fee-for-service or insurance-based health systems in other countries. Under the plan – legislation permitting – NHS data will be made more readily available to industry through a commercialised model, and in time supplemented with population-wide genome mapping and insights from wearable technologies. All this, the plan implies, will be connected through the NHS App and Single Patient Record, creating (if pulled off) a substantial treasure-trove for industry and research.
As the plan notes: “If the primary ‘factors of [economic] production’ were once defined as land, labour and capital, then today and in the future data will be at least their equal”. By promising an “unlocking” and expansion of that data, the plan hopes to attract inward investment for new drug discovery and the development of medical technologies on UK shores, employing British workers and recharging the stagnant UK economy.
Beyond the NHS’s current and future data hoards, further investor attractions set out in the plan involve a review of regulations to “create faster, risk proportionate and more predictable routes to market”. That marketplace – the NHS – is highlighted as particularly beneficial to investors in innovation as its relative centralism and single-payer status gives it “the means to universalise the best innovation for all” with minimal marketing expenses. That is a characteristic the plan proposes to emphasise further through “innovation passports” – an extension to NICE’s funding mandates from recommended drugs to also include medical devices, diagnostics and digital products, and greater NHS involvement in commercial clinical trials as well as faster regulatory approvals for these.
To these measures, the Life Sciences Sector Plan adds that a “growth mandate” will be placed on both NHS procurement activity as well as on the National Institute for Health and Care Research, and lists a series of key performance metrics to track the speed at which new drugs and technologies are assessed, adopted and spread. As an overarching target, it sets the ambition that the UK will be the leading life sciences economy in Europe by 2030, and third in the world after the US and China by 2035.
As if the vision of surgical robots, home bio-sensors and precision medicine was not sufficiently ambitious and futuristic, the investor pitch is underpinned by a promise that 3% (or £4.7 billion at 2025/26 funding levels) of the NHS commissioning budget will be committed annually to investment in transformation, including the adoption of new technologies. The plan sensibly refrains from setting a specific timescale for that pledge, which would entail a reversal of the current financial reality, where local health systems will, at best, end the current financial year £2.2 billion overspent.
The recent history of the NHS’s attempts to join up its data, even for its own internal use, suggests the path to implementation of this vision will not be smooth, while plans to deregulate the health care research and technology industries will doubtless face calls for scrutiny.
If you can’t beat them, join them
But the ambition highlights a deeper existential dilemma for the NHS: while some of the predictions on the use and scope of technology within the plan might turn out to be overstated, the trajectory of ever-more precise, individualised and consumer-orientated medicine and diagnostics is happening, whether the UK plays a part in its development or not. In today’s age of globalised media and communications, treatments and diagnoses that are available in one part of world are quickly also demanded everywhere else. In a global order trapped in the paradigm of relentlessly pursuing economic growth, this seemingly leaves the UK with a choice between being a passive recipient of rising health care demand or competing to become an economic beneficiary of it. The subtext of the plan is that this economic force cannot be beat, so better to get ahead of the curve and join it.
Multiple questions and concerns flow from this, including whether the net effect of further market-driven health care innovation will be positive for population health – recent analysis challenges the assumption that this is necessarily the case.
Eating the cake
More immediately, however, is the question: will ratcheting up the UK’s role in global health care innovation simultaneously turbocharge domestic demand for health care consumption, meaning the economic cake might be enlarged but so too might our appetites – leaving the problem of health care consuming an ever-increasing share unresolved?
There are reasons for concern here, not least because the history of health care innovation is the history of increased cost as new treatments and diagnoses extend the horizon of what is possible, or even seen as a health care need, through the lowering of treatment thresholds. This drives up demand, including for treatments where benefits are very marginal or near-negligible.
While a set of the technological advances envisaged in the plan are foreseen as facilitating a shift of patient care out of acute setting settings (where the largely untested assumption is that this will lead to a reduction in health care resource consumption), sizeable parts of the plan focus on the health-concerned well, rather than those in bad health. Indeed, the plan states the intent to remove gatekeeping mechanisms which current limit access to diagnostic tests, and to “transform access and convenience for those generally in good health”. The vision goes further, setting out a future where data from consumer health and wellness wearables are integrated into the giant NHS dataset and single patient record, accessible via the app.
As a consumer offer, the vision may well be popular. Recent developments in the fast-growing wellness market – noted in the plan – indicate substantial consumer demand for blood and other bio-marker tests among fit, healthy and relatively affluent people concerned to improve their sporting and professional performance, increase longevity, or to reduce relatively minor complaints that are below current thresholds for diagnostic exploration within the NHS.
Algorithm-enhanced marketing strategies can be expected to augment this demand further – all the better to facilitate further growth, not to mention soak up excess capacity left in the sector after rapid expansion in the home testing market during the pandemic.
An additional feature of the market is the recent emergence of wearables explicitly marketed to those wishing to monitor and evidence symptoms they feel have not been adequately recognised by the NHS specifically or by clinical professionals more widely. Although the patients concerned may personally value the ability to integrate data from these devices into their NHS record, and to communicate the results directly with their GP through an app, that development would also represent an increase in demand for health care resources for which the evidence of overall health benefit is unclear and services currently unprepared.
Similarly, the costs and benefits of a “new genomic population health service”, heralded by the plan, are unclear. As well as genomic sequencing for all newborns, the plan sets out how the service will provide polygenic risk scores to assess individuals’ risk of developing particular diseases, enabling early pre-emptive or preventative health care. However, as with all non-symptomatic screening programmes, genetic screening carries with it the certainty that a significant number of people will be over-treated as they are wrongly identified as at risk, when in fact they are not, yet still undergo harmful and expensive investigations or treatment – again diverting care away from those in actual need. Of at least equal concern are those whose polygenic risk score will suggest they have low risk and are falsely reassured, disengage from lifestyle advice and conventional screening as a result, and yet go on to develop the disease.
Those who wrote the plan will not have been unaware of these risks. Yet the gamble they have chosen – in the context of a political culture reluctant to consider alternatives to ever-increasing consumption and a nagging doubt over middle-class approval for universal health care – is that the NHS and UK can both ride the wave of industry growth and tame its demand-inducing effects through “pre-emptive” health care that avoids acute care costs in the future. If the gamble is lost, the result will be an NHS that does more but achieves much less.