NHS reform plans: prevention, personalisation and personal responsibility

Last week, the Rt Hon Sajid Javid announced his vision for reform of the NHS, outlined in a speech at the Royal College of Physicians and writing in the Daily Telegraph.

The problem: spiralling costs

The Health Secretary said reform was urgently needed ‘because we can’t just keep pumping more and more money into healthcare’. This is very true. The UK’s health spending rises all the time, with equivalent annual expenditure by 2018 over ten times the level it was in the NHS’s first year of operation, 1948. Whilst these increases in health spending are in response to rising needs (and costs), it is also true to say that it is not sustainable, especially as the increased resources needed is unlikely to be available in the years to come due to lower levels of economic growth and other national priorities.

The solution: prevention and personalisation?

The case for reform is that, since a high proportion of NHS costs ‘go on treating preventable conditions’, more effort should be put into prevention. So far, so good: prevention really is better than cure, and usually a lot cheaper too. Nor is this thinking new; the 2019 green paper on public health, Advancing health: prevention in the 2020s, promised that the then government would place a stronger focus on prevention and more specifically on a new model of personalised prevention.

The new 2022 white paper, Health and social care integration: joining up care for people, places and populations, focused on general plans for integration of care at the local ‘place’ level – and many details of how this will work in practice via the new Integrated Care Systems (ICSs) are yet to determined. Much policy analysis has been devoted to these complexities. However, plans included that by 2025 each ICS would host a ‘population health platform’ utilising data to support ‘proactive population health management and precision public health’, and that the NHS would enable individuals to access ‘personalised information about their health and care – to give them more control over their own health and care journey’.

This all sounds very positive, and in many senses the Health Secretary’s recent remarks seem in line with this framework: ‘My vision for reform will start what will be one of the most significant transfers of power and funding from the state to individuals and their families in decades’. The reasoning seems to be that a combination of access to high quality information and data, innovative technologies and personal choice (including over care) will deliver better health, including reductions in cost and health disparities.

Making the most of technology for health

It is true that delivering robust, reliable systems for collecting and safely sharing personal health and care data offer enormous benefits to the NHS and citizens – for more joined up and personalised care, as well as to underpin research for further improvements in care. Digital transformation of the NHS is widely recognised as an imperative to achieve this; whilst the pandemic accelerated progress, there is still much work to be done to achieve this. Whether the new focus on local care will create further barriers remains to be seen.

Similarly, rolling out useful innovations across the whole NHS so that people everywhere can benefit is essential, so a commitment to ‘make sure that innovative solutions don’t just stay where they are, but go far and wide’ from the Health Secretary is welcome. The PHG Foundation has repeatedly called for more efforts to underpin widespread clinical implementation of innovations outside centres of research excellence, enabling non-specialist health professionals to easily adopt proven improved practices for patient benefit.

However, as our submission to the 2019 prevention green paper noted, we also ‘strongly support a robust evaluative approach to applications of biomedical and digital technologies for prevention’. That is, enthusiastic as we are about the potential of innovative technologies to improve both prevention and care, not all will work in reality – so the focus should be on those shown to be effective. Javid notes his enthusiasm to ensure that more people have the NHS App so they can receive ‘personalised advice to manage their own health’. This is a very reasonable ambition – but it is important to be sure that access to personalised advice does genuinely support effective health management and improved health outcomes in practice.

The limitations of personal responsibility

Whilst few would argue against the concept of more personalised care, the term ‘personalised’ seems to be serving multiple purposes in the latest policy announcement. Caution is needed when moving from consideration of population level data and insights to individual assessment, and further care when making assumptions about the link between information and response.

Whilst personal choices and behaviours are critical in underpinning better prevention of disease and maintenance of health, and while data and technologies have undoubted scope to help inform and guide these choices and behaviours, it is rarely that simple. Biology in health and disease is complex, and individual, and so are personal circumstances and capacity.

The Health Secretary’s assertion that we ‘all need more power to determine our own health’ is perfectly correct; we do, alongside wider developments to make our environments and circumstances more supportive of living healthier lives. Investing in prevention is badly needed, and personalised prevention will be a valuable enhancement of more general population-level approaches. However, the mantra of personalised medicine, one size does not fit all, applies to personalised prevention too. People are different. Their ability and willingness to participate in protecting their own health will vary, and whilst data and technologies can undoubtedly help refine risk assessment and prevention strategies and offer new forms of support, one solution simply will not fit all. Policy needs to keep this firmly in mind if new approaches are to genuinely improve health and narrow existing health inequalities.

The PHG Foundation report Our Healthy Future firmly advocated for future health systems to adopt a holistic, data-driven but person-centred approach to disease prediction, prevention and management. This means combining precision approaches with due attention to personal priorities and needs. However, whilst enthusiastic about the potential of new science and technology to deliver better and more sustainable future care, the report also warned of the need for policy to protect against the risks, including widening health inequalities, increasing overdiagnosis, and undermining individual choice and autonomy. The health and care paper does acknowledge this, calling for ICSs to deliver personalised and predictive care based on an individual’s risk whilst also ‘recognising the impact that factors outside of health and social care can have on the outcomes that people achieve’.

Going forward, it is vital that the government should continue to support this approach – but whilst so doing, also take great care around the language of personal choice with respect to disease prevention, and ensure that the utility and impact of new tools, technologies and approaches are thoroughly assessed.