NHS at 70: ‘The challenges are enormous, but the NHS can survive and adapt’
Dr Matt Kearney is National Clinical Director for Cardiovascular Disease Prevention for NHS England, and a practising GP. As the NHS celebrates its 70th anniversary, he tells us in his own words why the NHS can – and must – evolve.
19 June 2018, by Dr Matt Kearney
If we embrace the opportunities offered by personalised medicine, artificial intelligence and better access to health information, that is the NHS which will survive in future.
Personalisation, which largely comes from the growth in genomics work, is going to have an enormous impact. It will give us more insight into conditions that you might develop and how outcomes can be changed.
For example, with hypertension some people respond really well to a low dose of a blood pressure (BP) tablet and some need two, three or four drugs, and still their BP is not as well controlled as it could be. Different individuals respond at a molecular level to different drugs. The same may be true of warfarin, and there is a large clinical trial under way to look at this.
BHF Medical Director Professor Nilesh Samani has talked about the genetics of risk and how that is likely to evolve. We already have the NHS Health Check programme, where we try to predict the level of someone’s risk [of cardiovascular disease] in the next ten years. Genetic advances will allow people to be more aware of their real risk and act on it. That will result in more targeted treatments.
It used to be that to get information about your health, your doctor told you what you needed to know. But health information is becoming democratised.
People are now self-testing their BP and peak [expiratory] flow rate, INR (international normalised ratio for anticoagulation) and their blood sugar and cholesterol levels. And there are wearables that allow you to measure steps, heart rate, sleep quality and so on. There are contact lenses that can measure blood sugar on a continuous basis if you have diabetes. There are also wearables which can measure your body water content. In future, you could use that to adjust your diuretics for heart failure.
Wearables, and data people derive from them, will give people much more information and help with treatments.
All this is just scratching the surface. This will enable people to become more knowledgeable and support the doctor with decisions, rather than just the doctor making decisions.
Changes in roles
GPs today do a lot more specialist work that only cardiologists used to do. And you have very specialist GPs in cardiology or respiratory. Nurses are now much more specialist and do things only doctors used to do.
The next step is that patients will be the experts. Patients already have expertise, but what if they can do their own measurements to inform this? I think this is going to evolve dramatically and change relationships in medicine.
There is so much happening in artificial intelligence at the moment. For example, Google is working with the Royal Free London NHS Foundation Trust to use data to detect kidney injury and which patients will need treatment.
Artificial intelligence is being used for analysis of scans and mammograms, and for therapeutic purposes, for example to support mental health.
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Public Health England has created a Breastfeeding Friend, which allows mothers to get support via Amazon Alexa or Facebook Messenger. It is an evidence-based intervention to support you that is algorithm-driven – you can ask questions and it will answer or point to other support.
Waiting two weeks for a GP appointment to discuss breastfeeding or mental health support may be too late. If you can go online at midnight and get support and directed to other places, that could really help change the offer from the NHS.
There is a lot of anxiety about how data is going to be used but I think this can be mitigated.
‘Diabetes alone could break the bank’
I think maybe the biggest achievement is that the NHS has survived 70 years broadly intact in the way it was envisaged: as a free-to-all, cradle-to-grave service. But the problems facing the NHS are much broader in the 21st century than they were in 1948.
How do we use all this - personalisation and health information and artificial intelligence - to adapt and survive? We have to evolve. It comes down to our sustainability.
Our biggest challenge is the growth in preventable illness and how that is increasing demand.
How are we going to survive with the growth of obesity and long-term conditions? Diabetes alone could break the bank. Diabetes already takes 10% of the NHS budget. If that continues to grow it is only a small amount of years before we don’t have money for anything else in the health service outside diabetes.
Doing prevention differently
We have to get better at prevention. We have to join up better with housing, social care and employment [services], which are the other things that can affect people’s health.
Prevention is not just about drugs. It is about mobilising the population and taking action around health. We can use health information to do that.
Historically, acute care is what we are good at and that has driven change. I think our past neglect of prevention is changing, but it is slow. The challenge of prevention is that it delivers later, but the problem is immediate. The challenge for NHS organisations is always getting through this financial year. As a nation we are still in an austerity programme. Financial pressures do make it very difficult. I think the way around that is to keep it on the agenda and keep articulating the benefits of prevention.
We can make it easier for NHS bodies to make prevention decisions. The BHF is helping with a return-on-investment tool that the NHS is developing. Local authorities or NHS bodies can look at their area and see if they take steps to manage high BP or cholesterol more effectively – this is how many heart attacks and strokes it could save.
A lot of our work with the BHF and others is to create new models; for example, community pharmacists taking over management of BP and atrial fibrillation (AF) from GPs.
The BHF is funding a service with BP testing pilots across the UK. Rather than just saying, ‘GPs, you need to work harder,’ we and the BHF are saying: ‘Let’s use a model where people are getting their BP tested in the community before they go to see their GP.’
We can rail against the fact that there is no money. Or we can challenge ourselves around what can we do differently and how to use resources differently.
I feel very positive about the NHS. The challenges are enormous but I believe the NHS can survive and adapt. It can be done.
Interview by Sarah Brealey
More on the NHS at 70
Our patient magazine, Heart Matters, has published a suite of articles in time for the 70th anniversary of the NHS.