Our health in 2040: are we getting sicker? – with Jeanelle de Gruchy and Kevin Fenton

• The Health Foundation (2023). Health in 2040: projected patterns of illness in England.
• UK government (2023). Major conditions strategy: case for change and our strategic framework.
• ONS. Rising ill-health and economic inactivity because of long-term sickness, UK: 2019 to 2023.
• The Health Foundation (2022). Addressing the leading risk factors for ill health.
• The Health Foundation (2022). Is poor health driving a rise in economic inactivity?
• The Health Foundation (2022). Health is wealth? Strengthening the UK’s immune system.
• UK government (2021). Chief Medical Officer’s annual report 2021: health in coastal communities.

Jennifer Dixon:

Are we getting sicker? The government has just published a framework for its forthcoming major condition strategy, but whatever we are doing on health, it isn't turning the dials nor preparing care services enough for the massive wave of morbidity that is clearly in sight.

We know the UK population is ageing and we know we collect illnesses as we get older. Recent Health Foundation modelling estimates that 1 in 5 of us will be living with major illness by 2040, mostly because more of us will be older. But it's not just about age, already a record 2.6 million people of working age aren't working due to ill health, many living in the poorer parts of the country. What on earth are we going to do differently?

Well, with me to discuss this, I'm pleased to welcome Jeanelle de Gruchy, Deputy Chief Medical Officer for England and lead for the Office for Health Improvement and Disparities at the Department of Health and Social Care. And Kevin Fenton, who is the President of the Faculty of Public Health. Welcome both.

If you stand back and look at Britain, what you see like many other European countries is there's demographic change, which is looking a bit scary. So more older people, which in itself is not a problem, but there is also going to be fewer younger people in the next 30 years or so because of the baby boomers retiring and lower fertility in the 1970s. You've got the demographic issue, you've also got increasing health needs: 1 in 4 of the population already having two health conditions, 2.6 million people of working age not working because of ill health. You've got an increasing morbidity load in the working age as well as in the older age group. This is really quite sobering, isn't it? If you look back over the last 30 years, you have to ask, has anything turned the dials on some of either the risk factors or indeed some of these morbidity trends that we are facing?

Kevin Fenton:

When I think about the next 10 to 20 years clearly, as a public health expert, I focus on the health of the population, the health of the public. I'm also mindful not just only of the demographic change but the changes in the wider social and economic drivers of health. We've gone through a period of significant economic instability and change and we know that's having an impact on poverty, it's having an impact therefore on health. We're also dealing with increasing impacts of the climate, climate health impacts, climate change, and the need for us to adapt and to mitigate those changes as we move forward. That's going to have a major impact I think on trends and factors which are influencing the public's health.

As we've seen with the pandemic, we've seen the widening of many inequalities and the growing social and economic drivers of those inequalities, I think that's also another trend that we need to look forward to as well and to be mindful of. In summary, yes, let's focus on the demographic change and understand how that's impacting health, but let's also begin to think about how it intersects with other wider determinants of health both emerging and emergent, and then think about much more comprehensive approaches to tackling some of the issues which I'm sure we'll be discussing today.

Jennifer Dixon:

Jeanelle, what would you add to that?

Jeanelle de Gruchy:

I possibly would have a slightly more positive skew to things because otherwise that all sounds quite doom and gloom. And the fact that the baby boomers, including myself, are living longer is a good thing, right? Our living conditions have improved. We've really done a lot in terms of some of the factors for poor health, for dying young, so smoking particularly, but there are other things, vaccinations and antibiotics and all sorts that have meant that we are living longer. I don't think that's the issue per se. Because we are living longer, we also are having major health conditions and what we are wanting to do I think is to prevent the onset of those conditions or the number of conditions you might get as you get older, but also if you are going to get a condition that we delay the onset of conditions.

I think that's really important because it's the rise of the number of conditions and the long amount of time we have those conditions that is going to be the key issue, and I think Kevin quite rightly points out the inequalities inherent in the way in which we are going to age and age well. But just returning to that positive, I think the contribution by older people is already impressive and can be even greater if we improve older people's health, the quality of life, so improve their ability to contribute to society. But Jennifer, you also raised the issue around the working age population are fewer in number, and we really need to focus on ensuring that those of working age are living healthily.

Jennifer Dixon:

What's your take on what's happening with the working age population? If you devil into IFS analyses, Bank of England have done some work on why there is this growing amount of ill health in the under 65s. No one seems to know quite why. I don't know, what's your take on what's going on there?

Kevin Fenton:

It's hard to pinpoint a single factor driving that. I think clearly we're seeing a rising tide of non-communicable diseases and increasing prevalence of a number of the risk factors which drive those NCDs. We're dealing with higher prevalence now in many population subgroups, more physical inactivity, alcohol use and alcohol misuse, some warring patterns and trends. We know that in terms of people's ability to access healthcare services, that has been under significant strain more recently. Of course post pandemic, the mental health challenges and the impact that has on people's ability to both remain engaged in work and to have a productive work life as well. I think there may be multiple factors happening at the same time that are resulting in some of the patterns that we're seeing in terms of economic productivity and engagement in the workforce.

I also think the nature of work is changing as well and what people are choosing to do, how people choose to be engaged in the work. We know that we've seen people, especially as they've come through the pandemic, making active choices to reflect on their work-life balance, the type of work they're doing, or have had to change careers as well. That may also have wider impacts on how people are engaging in the workforce.

Jennifer Dixon:

One of the key patterns in the working age population is of course the people entering the workforce, the younger people, where there's been a really noticeable jump in mental ill health, a 70% rise in that group. Jeanelle, has that been on your radar screen?

Jeanelle de Gruchy:

It's been quite dramatic, hasn't it, the rise in mental health? Some of that will be how we understand, talk about, characterise what a probable mental health condition is or a mental health disorder, and some of that is good, right? The stigma has gone down over recent years, people are more able to talk about mental health, people think about what's happening to them more in terms of their mental health. I think there's an element of that. But it's certainly a real concern for us. You talked about working age and that impact about mental health is really important. The interplay between mental health and physical health is a key one and sometimes extracting out what's going on, but the interrelationship, I think we are understanding that more. I wonder how that's going to impact on the way in which we develop our interventions and our approaches over the next years, because there's no doubt that the evidence base around physical conditions and what we do about them is pretty strong in most of the major conditions.

When you come to what do we actually do in the prevention space around mental poor health or mental disease, it's actually not as well-developed at all. I think that will emerge over the next 10, 20 years. Well, how do we actually prevent, how do we ensure that we intervene early with appropriate interventions and really make a difference to the outcomes for people who are unfortunately having mental health problems?

Jennifer Dixon:

On that, I notice in the multiple conditions strategy that the global burden of disease study couldn't really focus on mental health because it couldn't identify obvious risk factors that were very active ingredients because there were so many. But do I take it that you think that the evidence base could possibly improve to the extent that we could identify obvious risk factors rather than the plethora of what we know now, but it's difficult to prove like early life stress and all that?

Jeanelle de Gruchy:

I think we need to know a lot more about what the risk factors are and then what we actually do about them, and that evidence base definitely needs to improve. We need to pay far more attention to what actually works. There are things that we do know make a difference where we have stronger evidence. We do know that attachment in the very early years, giving children the best start in life, that's really important. We know that interventions at school age, dealing with bullying and that phase of young people's lives that there is evidence around that. There is some evidence around the working age population. But really when we know that by the time you're a young person, if you've got a mental disorder, it tends to manifest itself by teenage and early young adults. We really do need to ensure that we've got the services there, the interventions that are evidence-based so that we can really positively intervene at that moment to help young people and to reduce the risk that they're going to have a mental health condition for the rest of their lives. That early years is really critical.

Jennifer Dixon:

Let's just turn to what are we going to do about some of these trends. Jeanelle, you were quite positive about some of the trends quite rightly, reduction in smoking for example But other areas are looking quite worrying. Stepping back over the last 20 years or so, I mean just think about obesity, nothing really has made a dent, just to mix metaphors, in some of the trends here. Our analysis that we published recently showed that if we continue the way we are on risk factors, actually these long-term conditions are going to appear earlier. We've had lots of different approaches to various aspects of wider health over the last 30 years or so, but nothing that is comprehensive. Actually many researchers have said how limp and repetitive some of the approaches have been, for example, to obesity, diet and exercise, and so on.

Given these trends, what are we going to do differently that's stronger and more effective in future? On this, perhaps I could turn to Jeanelle first because clearly we've had the approach and framework set out to at least one aspect of this, which is the latest planned forthcoming major condition strategy, which was published on 14 August.

Jeanelle de Gruchy:

I do think some policies over the last 30 years have made a difference and some of them have been incremental. If you take tobacco, stopping smoking in cars for instance with children, the smoke-free workplace is a big step change, really, really a big one. All of those collectively have driven reduction in smoking. I do think with... We'll come back to obesity, shall we? But let me talk briefly on the major condition strategy. A key for me in this is what that framework does is group the major conditions which contribute about 60% of morbidity and mortality, the cancers, the cardiovascular disease, musculoskeletal, mental ill health, dementia, and chronic respiratory disease. As I'm listing them, you can think, well, that's interesting because there's going to be a cluster of risk factors that is quite common to quite a number of those major conditions that we need to address through prevention.

Whether that's primary prevention or secondary prevention, there are some clustering of risk factors that we really need to address and get on top of. Then, for some of those conditions, early diagnosis and treatment or end of life care are really very important as well. Those conditions clustering together, again, what I like about the way it's framed is we need to think about somebody experiencing multiple conditions at the same time, and are we gearing up our services to really meet those needs? I think that relates back to the Health Foundation report, which points to the change or the shift in people living longer with more conditions at the same time. But to your point I suppose about primary prevention, do you want to come to that now, Jennifer, or...?

Jennifer Dixon:

Before we do, I mean I guess clearly the strategy as the framework, it looks to me as if it's being quite pragmatic. It's got a 5-year timescale, it's addressing major conditions, it's looking at primary and secondary, but it's quite focused and it's I think driven by evidence, quite clinical, seems to be a useful list of existing initiatives, nothing particularly new. I mean, there was the stuff in the press, wasn't there, but that's the inserts to the cigarette packets and so on. It emphasises personalization, individual choice, all that. I can see that might be pragmatic given where we are. But I guess the question is, is that really going to term the dial both in really helping the huge wave of older people manage their condition, but also to help the working age population to prevent, as you say? Are you hopeful that there'll be something a little bit stronger that is really going to do the trick?

Jeanelle de Gruchy:

Well, I think our job really is to set out what the evidence is for what is needed. I think it's really important that we make the case. I feel very strongly about making the case for prevention, preventing those diseases and preventing the early onset of those diseases. I think some of the choices you're pointing to are going to be political choices politicians make on behalf of society, and certainly primary prevention is very much in that political space. If you take obesity, we are going in the wrong direction, it is very concerning. The figures around childhood obesity are quite concerning, and really the disparities within that where children in more affluent areas, you're not really seeing a rise in obesity, but you certainly are in children in the more deprived areas. How does that play out over their life course? That's really very concerning.

I don't think that we yet know what will absolutely shift the dial on that, but there are enough things that we do know where if there's political will, we can make a difference. As I said, we need to really put in place incremental changes because small changes in primary prevention, secondary prevention will make a difference over time. But I think these are big political choices that really are in the remit of the politician. I think our role as public health professionals is to put the best evidence base we can in front of politicians, and reports like Health Foundation which show what those trends will be over the next 20, 30 years are really important.

Jennifer Dixon:

Kevin, I'll ask you what you make of the major condition strategy in a minute, but if you just step back, away from that and think about the wider determinants and on a longer time timescale, not the 5 years of the major condition strategy, but maybe a 30-year so you're really thinking about health capital more widely and what to do about it. Given that you aren't in government at the moment, because you are President of the Faculty, how do we keep this kind of agenda alive, kicking, and active? I mean, Michael Marmot's done a good job, hasn't he, whether or not you agree precisely with his diagnosis or indeed the solutions. There is something, isn't there, about continuing to bear down on the wider determinants in the face of what is inevitably not going to be strong evidence because of the multifactorial nature and dynamic nature of the influences on health.

Kevin Fenton:

That's right, and I think that's why we need to... While we build the evidence and while we invest in understanding those determinants and the interactions between the drivers of the patterns of disease that we're seeing, it's important that we go beyond the evidence generation, right? What you see is the importance of leadership of the profession, both in terms of the advocacy that we will do both at national, regional and local levels, ensuring that we continue to keep the health of the public at the forefront of political health and care leaders and other system leaders, ensuring that we continue to build the capacity of the system at all levels to ensure that we are continuing to deliver on the most effective programmes, that we're prioritising the use of scarce resources in order to have this population health impact that we need, and that we continue to build momentum even in the absence of perfect evidence.

There is a lot that we can and should be doing. While we all welcome the major condition strategies focus on a much more endemic or holistic approach to thinking about multiple conditions and chronic diseases, it really is important that the strategy sits within an environment where there is mobilisation, education, building capacity, delivering effective programmes as best as possible. I think that's a space that we need to be in as well. Now, when the time is right through that advocacy, through that leadership, through that building on best and emerging practices, we can begin to think about what might the next strategy look like and how do we begin to incorporate actions that can address some of these wider determinants.

Jennifer Dixon:

Clearly we're getting into election year, aren't we, within the next year or so, maybe next October, who knows? There will be a General Election, there may also then be a change in government, and so far it's quite difficult to discern from labour what they think about this. They obviously are open to wider determinants of health and acting on them, but whether or not it's a priority for them in the first year or so is a question.

Kevin Fenton:

Speaking as the President of the Faculty of Public Health, I think we're still a way off before we know exactly what's going to be in the manifestos, the direction of travel for parties who will be competing in the next election. I think what we need to do now is to build those relationships, so we're beginning to articulate both the evidence where we need to see investments and where we need to see action to both generate better health, improve the public's health to create a very clear narrative about the relationship between health, wealth, and the need to perhaps reframe health as being a core national asset, one which requires investment, one that requires maintenance, and of course building upon the narrative of economic productivity and health as well. There are things that we can be doing and should be doing now rather than being caught up into what one party or another party may be going forward with. I think it's how are we making the case now and are we laying the foundation to have the sorts of relationships that we need post-election to really advance this agenda.

Jennifer Dixon:

Just on that, Kevin, the health and wealth agenda, I mean you probably saw we had a nice lecture by Andy Haldane pointing this out that health was critical to the contribution to future prosperity and needed a long-term plan for it. Obviously there's been significant interest in clearly getting people back to work and claiming benefits and so on. Jeanelle, from where you sit, is this interest really alive? How do you see it from your perch at DHSE?

Jeanelle de Gruchy:

Yeah, I do think it's a live concern and certainly your analysis shows that we do need to pay attention to the working age population, but I think there's certainly a renewed focus on it, a real concern in terms of the increasing prevalence of disability amongst working age adults. I think you cited some figures, Jennifer, but the figures I was looking at was an increase from 15% disability in 2010 to 23% now. That's a big percentage change, but also in terms of numbers, that's of real concern. If you marry that with the trends in the older age population, I think it really does focus the mind in terms of the economics of that. I do think that this is a real concern for parties of multiple colours, of any colour really, and I think it does need to be addressed with a view to that longer term policies that will make a difference and creating a bipartisan view of the fundamental things that everyone should agree on or could agree on to try and shift things.

Again, if you take the issue around obesity, what we probably need to be doing are quite difficult politically. Having an ability to have agreement across multiple parties will really be quite important. Yes, I agree with you in terms of the concerns around economic inactivity or the link between health and the economy, I think there is certainly much more focus on that now. I'm not sure our evidence base is as strong as it could be, should be. I think there's more work we need to do to think about what do we do to address a lot of the economic inactivity from a health point of view.

Jennifer Dixon:

Kevin, we've spoken about this before, but there's also local government as actors and clearly there's more and more strength it seems, not in the budgets of course, but in the development of the mayoral system and combined authorities. How far do you see that local government collective has a voice in trying to influence national policy or indeed taking more responsibility to use the powers that they have to stretch them further into wider determinants?

Kevin Fenton:

Well, I certainly think that's going to be a key part of how we shape the future towards better health for the population and how we become more resilient to deal with some of these issues which are going to drive population health over the next 10, 20 years. We've seen the maturity of public health in local government over the past 12 years. We have seen the innovation that is emerging from local government, not just in the delivery of programmes supported by the public health grant, but really integrating the thinking of the responsibilities for improving the health of local populations and tackling inequalities and how that begins to play itself out in wider programmes, whether in terms of housing, community mobilisation, planning, regeneration, and social care.

I think that trend that we've seen over the past decade is certainly a positive one, and one which I think allows us to have another locus of energy, another locus of programmes and effort that can help to both not only compliment national actions to tackle some of the challenges of the next two decades, but also to look at innovative areas where government should be focusing on as well as filling in some of the gaps. Some of the things we're certainly looking at is how do you build upon or [inaudible] local government to unleash the power of local communities, to engage local communities in becoming part of generating health through understanding both their efficacy as individuals and communities, to build resources and infrastructure in communities that can be part of health generation, and to think about how we leverage the range of local government services to have health and wellbeing at its core.

Investments, for example, in community champions, really building upon social prescribers, thinking about the creation of ICSs, integrated care systems, and partnerships and how that allows new ways of thinking about community assets is only one example of what local government I think can and should be doing. Similarly, unlocking assets through working with businesses, through working with the NHS differently, really thinking about the dividends to be gained through education, through community safety. There's so many opportunities that we've seen over the past decades really coming up and developing with wellbeing at its core, and I think this is something that we should continue to support moving forward.

Jeanelle de Gruchy:

I wondered if I could pick up what you were talking about in terms of local government a little bit more, because I think your report looks at the whole population getting older and larger numbers of older people, but I think a key element is that population won't be spread evenly across the country. We know in terms of the demographic trend that people move to cities for study and work, but then when they start to have families or potentially as they get older, they move out. You've got an out-migration from the cities, and actually I understand that cities might look quite similar over the next 20, 30 years. Even London, I'll be interested, Kevin, about London in that regard.

But what's happening is that we can see by the data that parts of the country are getting net migration into them of older people, people over 65. You take your Norfolk or Devon or parts of Cumbria, and so rural, semi-rural, and coastal areas are going to have more and more older people in them. I think that element is going to be quite difficult because we know that that's happening, that also is predictable, but what then happens in those areas in terms of what they do to balance the larger needs of the older population, but having access to services or the workforce to provide those services is going to be quite a challenge I think.

Jennifer Dixon:

I haven't seen a NHS report equivalent to the CMOs report on coastal towns in this regard. Is there one on this issue, Jeanelle?

Jeanelle de Gruchy:

I think the CMOs new report will be on ageing and pick up some of these issues, I think, so that's a watch this space for that particular report as it comes out. But clearly we know that there is an increase in older ages, that it's not evenly spread across the country, and that some of those areas that I've referenced the semi-rural, the rural, the coastal, are areas of high deprivation. Not only will you have the demographic shift, but it's within parts of the country that potentially struggle anyway. I think we do need to be thinking about both policy responses and service responses to that trend.

Jennifer Dixon:

Yes, and resource allocation responses as well, which often lag behind in need, don't they? Good. Okay. We're nearing the end, unless you wanted to add anything, Kevin?

Kevin Fenton:

I did actually, on the early diagnosis and identification of both risk factors and diseases earlier. We have models now that give us a good idea about what happens when you begin to diagnose individuals earlier at an asymptomatic phase of their disease and the things that you need to do for them to be both engaged, empowered to develop their self-efficacy, and to be part of the solution in managing their chronic condition. A great example is, for example, the successful work we've done on HIV over the last four decades where we are encouraging people to know their status earlier. As a result of that, not only does that enable people who are living with HIV to take greater control of their disease, but also to make better decisions both for their health and the health of their partners.

As we move into a space where AI and technology may be moving the dial earlier in terms of being diagnosed or wherever risk factors, I think there needs to be a concomitant investment in what we're doing to educate patients, educate the public about health, providing the support for management in the community settings or outside of healthcare settings, developing the tools that enable people to both monitor their illnesses and to be educated about when they need to engage and how they need to engage with healthcare settings and may require whole new sets of diagnostic tools, management tools, digital tools to help that. This is one of the areas where I think I'm far more optimistic. I think as we move to earlier diagnosis, early engagement, we have a tremendous opportunity to have different conversations with the public now about understanding their health, taking more control, and being part of co-producing their health outcomes too.

Jennifer Dixon:

Just one last question. If you, again, stand back and look at the health trends, governments produce policies here, there, and everywhere. Indeed, local government might increasingly do this, but there doesn't seem to be a sort of obvious reckoning if you look at the population health in the round. Should there be an independent or regular audit of what is happening to the key dials on public health that is laid before parliament in the way that the carbon audit is done by the CCC?

Jeanelle de Gruchy:

I think what you're saying is holding politicians to account or about providing a comprehensive view for society, citizens and politicians to all have a look at. I suppose how that's done isn't necessarily a question I would answer, that's a political question about how that is done and packaged and so on. What I would say is that a lot of what we're talking about is known about that it will take political will, so that's really where we need to focus time and attention in terms of ensuring that politicians have the evidence, have the information to make those decisions on behalf of society.

Kevin Fenton:

I think that audits such as the one you described are necessary, but they certainly won't be sufficient. If you look across the economy, if look across society, we have audits on various other measures and priorities, whether it's climate, whether it's other measures that we use. As Jeanelle has mentioned, having the data, having the audits, having the measurements are necessary, but what you also need is both the accountability, understanding who is responsible for acting on the findings, how the system is geared towards implementing those findings and moving forward to addressing where there are gaps or where there are needs, and then finally, how you engage the wider society in owning these data, owning these findings so that they become part of co-producing those solutions as well.

Everybody's engaged in the cost of living crisis, we're engaged in whether the economy is performing well, we're not necessarily having that same public engagement about our health or worsening health. Yes, we're having it on access to the NHS and waiting times, but this is so much more than that. I think having the audit, understanding the accountability, understanding how we act on those data, and taking the public along with us I think will be key.

Jennifer Dixon:

So we must leave it there. Thank you very much to Jeanelle and Kevin for all their insights here. As ever, links to the reports and analysis we've referred to can be found in our show notes, so take a look. Next month we'll be asking, should we be worried by the increasing use of private suppliers backed by private equity to deliver NHS-funded care, so join us then. Meantime, many thanks for listening. Thank you to our staff at the Health Foundation, to Sean Agass and to Leo Ewbank, and also to Paddy and all his colleagues at Malt Productions. It's goodbye from me. Until next time, Jennifer Dixon.