We continue our series of interviews exploring the findings of our Health in 2040 report, which looks at how levels of illness will change in England over the next 20 years. Our detailed modelling projects that people will be living longer but in increasing ill health, with a 30% increase in some of the most prevalent long-term conditions.
Claire Fuller is National Primary Care Medical Director for NHS England. She’s also a practising GP and was previously Chief Executive of Surrey Heartlands Integrated Care System. She reflects on what these future projections will mean for primary care services.
Looking at the projections, what are you most concerned about and why?
The report talks about the increasing number of people who’ll be living with conditions such as type 2 diabetes, depression, cancer and COPD. It also projects that by 2040 someone aged 85 will have on average 5.7 different diagnosed conditions. I’m most concerned about the complexity involved in managing the health needs of someone dealing with many interconnected issues. And how that multimorbidity inevitably leads to increased frailty in older people.
The other thing that really stood out was the number of people who will be living with chronic pain. Which is worrying because as well as pain being complex to manage, people in pain often experience worsening symptoms for all their other ongoing conditions, including their mental health.
Most of the conditions projected to increase at the fastest rate are those typically diagnosed and managed in primary care. What impact could this have on primary care services?
I’d say that every single one of those conditions will start with diagnosis and management in primary care and only the most complex will receive onward referrals, so the impact on demand will be huge.
The number of patients needing to be seen will continue to rise – and consultations will continue to rise in complexity.
Patients don't come in saying, ‘I want to talk about my heart failure.’ They say, ‘I feel awful, I'm exhausted’ and then describe a list of things that they are worried about: ‘I get out of breath, my legs are swollen, I can’t lie flat etc’. The job of the GP is to recognise, prioritise, work out what needs the most attention, and where the biggest impact will be. But this takes time.
And these days we manage so much more within primary care. When I first started as a GP, if someone needed medication to treat high blood pressure, such as ACE inhibitors, they would be referred to have the drugs started in hospital due to the perceived risk. Now I’ll happily start multiple treatments in the surgery and monitor people at home.
What will general practice need to be able to respond to these trends and provide effective care?
The only way we’ll manage is by changing the model of care. We need to provide truly personalised care, in a way that works for people. And going forward it won’t just be about GPs, care will need to be provided by teams.
The frailest people with multimorbidity will need to be looked after by a joined-up neighbourhood team that covers all their needs. That may involve cardiological, renal, and diabetology input, but it will be led by a generalist clinician who can have that personalised conversation with someone about what matters most to them.
Continuity of care matters – being able to see the same health professional is so important, especially when you have multiple conditions. Please read Denis Pereira Gray on this, his research is the gold standard.
With so many patients on our lists now, it’s not always possible to offer this – but it doesn’t mean we can’t continue to prioritise it, especially with new methods of triage being implemented now. And if we can move to providing continuity of team, that will help.
Increasingly, new digital tools will also enable us to do things differently. Patients will increasingly be able to self-monitor, freeing up time. Take my dad. He has atrial fibrillation and takes warfarin, and he now monitors his anticoagulant care himself at home.
What can people in power do now to improve the lives of people living longer, and potentially with major illness, in the future?
It’s a lot about investing upstream. Investing in primary care to start to reduce demand rather than continuously create a reactive model in secondary care, and we must continue to make it as easy as possible for people to access care when they need it.
Setting up integrated care systems has been good for partnership working and joining up health and social care. But we still need a long-term solution for social care.
It’s also about investing in prevention. We know that if you move more, don't smoke, maintain optimal weight and drink sensibly, it can improve all your underlying health conditions. I know issues like obesity are really complex, but we do need to be helping people to make changes and create the conditions to make it easier for them to do so.
If we can get our data sharing and population health management right, technology could help. We could be targeting those most at risk and automatically linking them up with online smoking cessation or weight loss services, for example.
Your report is talking about the people who will be old in 2040. That’s me in 20 years’ time. But what about my children? What about the next generation on from them? If you look at our current childhood obesity rates, what will that mean for today’s 7-year-olds when they’re 70?
It’s the habits and health they’re forming right now that will affect their lives later on.
This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.