Back in 2010, Ogilvy produced the following report on the future of our Healthcare system with a 10-year horizon. Five years down the line, we cannow take the opportunity to reflect to see how closetheir interpretation of early signals of technical andsocial changes, are to becoming reality. In 2015,we can already see clear motions of change.

Clinical IT systems, traditionally once only updated by healthcare professionals, are now being continually updated via cloud-based electronic health records (EHRs) that integrate with multiple third party devices. Patients can access their own EHR, and update it with their own real-time data collected from wearable technology. This wave of a new generation of consumer wearable technologies are activating patients and encouraging them to self-monitor and self-manage. Through this technology, people are analysing their own body’s vital signs and making informed decisions to make their lives better.

Our homes have become smarter, and we are already starting to live amongst an intricate network of physical objects that connect with each other; our weighing scales are communicating with our smartphones to monitor our weight, our intelligent heating systems, accessed and monitored by carers remotely on their smart phones, are keeping our vulnerable loved-ones warm.

Accessing your GP surgery is becoming easier – virtual consultations and online triage are allowing greater access to see a trained healthcare professional, whenever, and wherever you are. Robotic surgery is already being used in many hospitals, gaining popularity as a less traumatic and minimally invasive alternative to traditional surgery. There are now programmes gathering and interpreting the data needed to develop precision medicine – the genetic codes of tens of thousands of people are already being sequenced to understand the links between our genes and our health, allowing us to create bespoke therapies and predict who will become ill.

As we approach 2020, what will likely happenin the next five years? There is certainly a direction of travel in combining advances in technology with the use of behavioural insights to unlock efficiencies and improvements in care. The explosion of social innovation we are already seeing in our everyday lives will begin to alter how people are involved in looking after themselves and others through social prescribing and patient activation. Supermarkets will likely be unlocking the valuable data they mine from existing loyalty cards, to direct us to products suitable for our medical conditions.

The home will become even smarter, and devices will be able to proactively challenge and change our behaviour, monitoring our adherence to medication as an example. With the recent outbreak of Ebola, it also seems highly likely that geolocation services on our smartphones/wearable technology will be able to alert us to high risk infectious areas in future epidemics.

For the other portends of the future from 2010, we will need to take a realistic look beyond 2020. Healthcare systems are struggling – investment in the power of engaging people and improving our knowledge and understanding will be the most powerful tools to keep it sustainable. There will of course always be advances in technology, medicines and systems but heavy public funding investment might take longer to procure for some of these 2020 visions; brain-computer interfaces, growing our own limbs and true personalised polypharmacy based on our genetic makeup will come one day, we might just need to extend our horizons a little further.

Claire OatwayChief Operating Officer

Tim BrayGP Partner & Research Lead

20 November, 2015

2

Introduction & overview

3

This map shows 8 ‘zones’ of health engagement from a psychosocial, or health psychology, perspective. For any particular aspect of our health, we are likely to ‘move’ through several of these zones as we experience and process symptoms, outcomes and information made available to us.

It is rather straightforward to present a fantastical, idealistic image of the future. But our intention here is to combine the ‘what if?’ with the trends that we at Ogilvy already see: a vision of thoughts and ideas that we believe will be achieved over the next 10 years. We have dramatised this vision as 20 scenarios of what our digitally-driven healthcare might look like in 2020, hence 202020 VISION; how all of us will be engaging with our own health and the health of our family and friends in the year 2020.

Predicting the future is not an easy business:

“This telephone has too many shortcomings… as a means of communication… the device is inherently of no value” Western Union internal memo, 1876

“Everything that can be invented has been invented.” Charles H. Duell, US Patent Office, 1899

“I think there is a world market for maybe five computers”Thomas Watson, Chairman of IBM, 1943

4

“There is no reason for any individual to have a computer in their home” Ken Olsen, President and Founder of Digital Equipment Corporation 1977

What we know for sure is that everything that can be invented has not been invented.

A HUMAN PERSPECTIVEWhat we also know is that health is a human business and so we have approached 202020 VISION from a human, ‘biopsychosocial’ perspective. As Osler, a great nineteenth century expert in internal medicine noted: “The good

physician treats the disease but the great physician treats the patient who has the disease”.

So what is a ‘biopsychosocial’ approach? It looks at the interaction of our biological processes with our thoughts, feelings, beliefs, behaviours and their social context. It is common sense and an empirical fact that social and psychological factors affect health; yet it is by no means universally accepted.

In our view, technology, particularly that which has driven social media, already has had a profound impact on the psychosocial context of health and healthcare. And this will continue at an accelerating pace up to and beyond 2020.

5

We have mapped a psychosocial context into 8 ‘zones’ of health engagement and have presented our 20 ideas for 2020 as they could relate to these zones. We have pursued this approach to remind us all that a focus on technology alone is naïve.

We believe that the tipping point of future progress will be the widespread acceptance and adoption of ‘cloud-based’ electronic health histories (EHH), also commonly referred to as electronic health records (EHR) or electronic medical records (EMR), accessed at any time, any place, anywhere, through personal multi-functional devices (PMFDs), the ‘smartphones’ of 2020. This for us is a must, it is the ‘digital glue’ that will

allow technological advances to interact with our bodies and our lifestyles, that change and evolve throughout our lives.

INTERVENTION ACROSS 8 HEALTH ENGAGEMENT ZONESBy 2020 ‘preventive health’ (zone A) will have become big business for industries that were once on the fringes. Genetic profiling will have gained widespread acceptance helped by (health insurer) incentives to prevent disease progression. There will be further incentives to participate in screening for conditions that have been identified as risks. All of this will be easy and much of it carried out on our personal multi-functional devices (PMFDs) – the ‘smartphones’ of 2020.

6

Crucial to public acceptance of these advances will be highly targeted communication campaigns demonstrating the ease of testing / screening and comparing and contrasting the benefits of early, pre-clinical intervention, versus the effect of delayed treatment.

Leading companies within the food industry will have embraced the regulatory challenges associated with evidence-based preventive health and we envisage partnerships and alliances with the pharmaceutical industry. Some indulgences in 2020 are likely to have both psychological and physiological benefits… and many consumers will be happy to pay a premium for these pleasures.

When it comes to ‘perceiving & interpreting symptoms’ (zone B) and ‘responding to symptoms’ (zone C), technology willprovide enhanced personal monitoring of our bodies at a pre-symptomatic level via miniature implants that will feed thisinformation to our ‘cloud-based’ electronic health histories.Diagnostic algorithms will then help us interpret oursymptoms and help guide our responses.

Our subjective, emotional representations will be enhanced by data collected from our biological processes, enabling some decisions to be automatically made for us. ‘Self care’ (zone D) will take on a whole new dimension.

Such data will be power. Today’s online patient groups will become increasingly influential patient co-operatives as their

7

access to automatic, anonymised members’ data is sought after. And at the same time, every item that we purchase is likely to have a health value attached to it, driven by global supermarket chains, that will aggregate data and use this to increase market share through wide-ranging health offerings.

The ‘professional consultation’ (zone E) will have been transformed in part through virtual interactions. Doctors’ ‘visits’ will be more focused and patients' expectations better managed. Both virtual and real interactions will be enhanced by tailored outputs, many of which will include videographic simulations that model an individual's future health, depicting the consequences of decisions and behaviours. The impact of

this powerful imagery on our responses to healthcare recommendations cannot be underestimated.

When engaging with ‘hospitalisation & surgery’ (zone F), we will start to see a hi-tech, hi-touch polarisation of health provision. Human judgement and involvement in some procedures will be verging on the obsolete with advances in imaging and robotics.

We predict global health providers will have partnered with leading brands in the hospitality business to create a substantial health tourism industry that leverages the benefits of psychological nourishment on recovery. We will also witness a whole new era in medicine: advances in tissue and

8

organ regeneration for both therapeutic and cosmetic purposes.

‘Long-term care’ (zone G) will become increasingly important as we continue to live longer, afflicted by chronic disease. We will, however, see a transformation in how we engage in this care. Assisted by genetic profiling and electronic health histories, we will see personalised polypharmacy, with individually tailored dosing. And many of our medicines will transmit data to confirm when they have been taken and how they are working with the body. A number of medicines will be replaced by gene therapy.

And finally, within ‘terminal care’ (zone H), we will see the use of mind-reading technology that is already available, applied to help people better realise their very final wishes.

COMMUNICATION IS KEYIf we are to effect the true potential that ‘technology promises health’, we need to remind ourselves that we are not machines but idiosyncratic human beings, with hopes and fears, stimulated and shaped by the media, family and friends.

Public and individual patient communication will be the key to unlocking the benefits of new technologies. To achieve this we must all keep in mind:

9

• Technology in itself is not a panacea; it needs to be adoptedand incorporated into our everyday behaviour.

• Technology will give us tools to do a lot more, but theinformation that these tools will gather must becommunicated and interpreted effectively to changebehaviour.

• Information is ineffective if we don't understand it in thecontext of our everyday lives, and information overload willhave to be managed. To cut through the ‘clutter’,information will increasingly need to be communicatedthrough storytelling and information visualisation(infographics), whereby it is portrayed in ways that tell visual

stories. The provision of information / knowledge / understanding will become an art and a science.

• New technologies to map and track individuals’ attitudesand behaviour will allow us to create the right messagewith the right tone in the right place at the right time.

• General health prevention messaging, that we often switch-off to today, will speak to us as individuals, tailored to thespecific lives we lead.

• Relative risk will need to be considered. Risk will need to beput into perspective and communicated responsibly toavoid the unnecessary fear that is a barrier to healthimprovement. Highly-targeted, persistent, positive

10

messaging will be needed to help overcome fear and embarrassment.

• Although health is a serious matter, we don’t always have totake ourselves seriously when it comes to healthcommunication. Gaming for example, is already a proven,highly valuable, communication tool that effects behaviouralchange as well.

At Ogilvy, our responsibility is to help the broader public and individual patients embrace technologies that are being invested in by the healthcare industry. We have already established strong partnerships with innovators in communication and interactive technologies and we have

started to bring together advances in medicine with those in communication and interaction.

Moving forward, we envisage working with all players, existing and emerging within the healthcare industry. By embracing behavioural medicine, science and technology, we aspire to maximise economic and societal benefit, thereby realising a healthier future.

11

12

Eight health engagement zones

This map shows 8 ‘zones’ of health engagement from a psychosocial, or health psychology, perspective. For any particular aspect of our health, we are likely to ‘move’ through several of these zones as we experience and process symptoms, outcomes and information made available to us.

13

There are essentially two kinds of preventive health – activities that promote better health (taking exercise, a varied diet, drinking in moderation, not smoking); and actions that help detect disease (self-examination, participation in screening).

All sorts of factors predict whether we will engage in preventive health activities including our age, sex, class, ethnicity and personality, the extent to which we believe we are susceptible to an illness and the perceived threat of a disease. We are also

influenced by the media or by friends and family as well as by the benefits or barriers to taking part. So, we may know that a sedentary lifestyle lowers life expectancy, and contributes to the development of various chronic diseases. And we may have heard that diets high in salt or fat are bad for us but many of us still find it difficult to exercise and eat properly.

Similarly, many of us are aware of the benefits of self-examination, particularly in the early detection of certain types of cancer. But still

Zone A PREVENTIVE HEALTH

14

A

some of us don’t practise these simple techniques for various reasons, including fear, embarrassment, lack of confidence or simple forgetfulness. We also need to volunteer to be screened by experts with better knowledge and technology and studies show that even if we do attend for an initial screening, as many as half of us may not go back.

For some of us, the fear of being ‘found to be ill’ is so strong that it has a negative effect on our attending a screening programme.

Education has been shown to help with certain groups – research shows that women who receive educational

programmes are 2–3 times more likely to participate in screening than those who don't receive the programme.

An invitation to participate in a screening programme may cause us to worry and become anxious, possibly because of a fear that the invitation itself implies the presence of the illness being screened. Those who find it difficult to balance these anxieties can become hypochondriacs or hyper-resistant to medical intervention.

Even receiving good news can make some of us anxious. Perhaps we feel we are just putting off the inevitable. For example with certain types of cancer that we know we may be vulnerable to, the result only shows that we haven't got the

15

disease – yet. And while we may feel relieved at finding we don't have a serious condition, we may also feel angry at the distress caused by the process.

Although our knowledge of preventive measures and availability of screening for new conditions will continue to increase over our lifetimes, the uptake of preventive health will continue to vary depending upon the demographic, social and personality factors of the individual.

16

Often, we only engage with our own health when we experience symptoms and many symptoms are so short-lived that they pass before we have time to think much about them. Symptoms are essentially the changes in our body brought about by disease. We may notice changes in bodily functions, emissions and / or sensations ourselves while other changes, such as those in our appearance or behaviour, may be noticed by our family and friends. We can however feel ill without having an identifiable disease, and we can have a disease without feeling ill, and

although some diseases have clearly defined symptoms, many involve a subjective interpretation of our body's response – feeling “sick”, tired, or pain for example.

We all practice `self-regulation' when it comes to our health. We view illness as an unstable state and we work towards re-establishing the status quo by appraising, interpreting and responding based on what we know. We learn about health and illness in the same way that we learn about everything else: through our own and others' experiences.

Zone B PERCIEVING & INTERPRETING SYMPTOMS

17

B

These experiences and our understanding of medical knowledge shape our `illness beliefs' and profoundly shape the way we perceive and interpret symptoms.

Saying this, symptom perception and interpretation are influenced by a number of factors:

Attention – we are more likely to be aware of and report symptoms when we are under-stimulated by our environment

Culture – shapes our expectations and assumptions about health

Gender – women report more symptoms and illnesses than men

Personality – if we're self-aware, we'll have a tendency to focus on our feelings and reactions and therefore symptoms

Context and identity – our perceptions of the symptoms we experience are dependent on our social identities: we have multiple social identities based on the contexts of our lives and our relationships with others

Stress and mood – if we're stressed we may believe we are more vulnerable to illness and so attend more closely to changes. We may also experience stress-related physiological changes (such as increased heart rate) and interpret these as symptoms of illness. If we're in a positive mood we consider ourselves healthier

18

Prior experience – We attribute new symptoms to previously diagnosed chronic conditions or with the ageing process.

So when we experience symptoms we usually try to work out why we feel like we do. Essentially we are trying to solve a problem and our approach will be based on the symptoms that we perceive represent a particular illness. If all the symptoms we experience relate closely to the beliefs and representations we hold for a disease, we are likely to interpret the symptoms as indicating this disease. But while we all experience symptoms, we're all quite different in the way that we act upon them.

19

The way we respond to symptoms varies widely. Whereas some of us may seek a doctor's attention immediately, others might turn to over-the-counter remedies for the same symptoms or wait and see if the symptoms subside or get worse. There are, in short, different pathways to health.

Our symptoms provoke an emotional representation (such as fear, anxiety, negative mood) that guides our coping responses. We may seek advice from family, friends and colleagues (our lay referral system) and

increasingly go online. This provides a ‘peer assessment’ of our symptoms, helps us label them, and crucially, helps us decide whether and when to go to the pharmacy for a ‘self-care’ remedy, (see Health Engagement Zone D) or visit our doctor.

While advice from family, friends and colleagues frequently incorporates rumour and gossip, it can provide all-important (if sometimes misguided) reassurance but, if their views are incongruent with our own, it is our views that tend to predominate. However,

Zone C RESPONDING TO SYMPTOMS

20

C

after seeking advice from peers, fear of disease and awareness of mortality still means that many of us put off seeking help.

Research has investigated some of the personality traits, lifestyle attributes and demographics that affect our approach to responding to symptoms. Some of us are described as ‘Severe Sufferers’. We take our illnesses seriously, fuss, pamper ourselves and keep trying new and different products. We tend to be younger, have children and are relatively well educated. But we are more likely to be anxious people and believe that we suffer more severely. Others among us are described as ‘Active Medicators’. We are on the same side of

the motivational spectrum as ‘Severe Sufferers’ and tend to use medication to relieve every ache and pain. We are emotionally adjusted to the demands of our active lives and are typically of average income and education.

On the opposite side of the motivational spectrum are those of us described as ‘The Hypochondriacs’. We have a deep concern over our health and have more conservative attitudes towards medication. We see possible dangers in the frequent use of medication, tend to be concerned over side effects and are afraid of medication with new ingredients and extra potency. We are strongly oriented toward medical authority,

21

seeking guidance in treatment. We tend to be older, not as well educated and more of us are female than male.

Also on this opposite side of the motivational spectrum, but even more so, are the ‘Practicalists’. If we're in this group we tend to accept illness and its discomforts as a part of life, without fuss and pampering and we are the least concerned. We use medication as a last resort and tend to be older, well educated, and emotionally the most stable.

22

Self-care in response to symptoms of illness is extremely common. According to at least three separate studies, we don't see a doctor for between 70% and 90% of illness episodes and if we do see a doctor many of us will have ‘treated’ ourselves beforehand. Self-care is often our initial response to illness, one sometimes encouraged by governments and other authorities (particularly in the current economic climate). In one study, over 80% of adults investigated had used at least one over-the-counter (OTC)

medication in response to symptoms that were later diagnosed as colorectal cancer.

For older people among us, self-care takes on a special significance – although we are more likely to see our doctor for physical checks when we are older, we will not necessarily see him or her every time we experience symptoms – despite the fact that we are more likely to suffer from chronic conditions. When we consider our symptoms to be serious however, because of the length of time we have experienced them or how

Zone D SELF CARE

23

D

much pain and dysfunction they cause, we are as likely as our younger counterparts to shift from self-care to professional care.

Opening up about our health issues to family, friends and / or colleagues can be beneficial to outcomes. It can help us to identify when self-care has run its course and thus lead to a more speedy consultation with healthcare professionals. Women are more open in these discussions than men, who are also widely believed to engage less with their peers regarding health issues, especially those deemed to be personally embarrassing.

The number of self-help groups that now exist has grown over the past 50 years. Members seek help not just for education but also for a shared experience, especially a shared misfortune. Overall, these groups can be classified as follows on the basis of why people join them:

• Physical problems• Emotional problems• Relatives of those with physical, emotional or addiction

problems• Family problems• Addiction problems

24

• Social problems (e.g. sexual non-conformity, one-parentfamilies, life changes, social isolation)

• Women's groups• Ethnic minority groupsAn important aim of these groups is to inform and refer as well as to provide counsel and / or advice. Therapeutic services under professional guidance and mutual supportive activities are also common.

25

The greater the number of symptoms we perceive and the greater our health concerns, the more likely we are to seek professional help. Furthermore, we are more likely to consult with a healthcare professional if we believe the outcome will be effective. Generally, we speak to female practitioners more than male and share more personal and medical information with them although this depends on our gender, social class and age, as well as the nature of the problem (i.e. how intimate or potentially embarrassing it is).

As patients we need to be aware of the importance of understanding and managing our expectations from a professional consultation. Our consultation agenda may be closely related to the immediate threats we perceive, such as continuing pain or how treatment will impact our lives. If we are anxious or stressed, or if we feel unfamiliar with the information being discussed, the outcome of the consultation can be affected significantly and we may not acquire the understanding that we need. Research suggests that some of us may lack the

Zone E PROFESSIONAL MEDICAL CONSULTATION

26

E

confidence to challenge what we perceive to be an educated and successful healthcare practitioner.

Research has also shown that the most important expectations to be met from a consultation were ‘understanding and explanation’ of the condition, ‘emotional support’ and ‘getting information’.

Other studies have shown that patients who feel more unwell and worried or have a high incidence of anxiety and depression or no paid work, show a stronger preference for good communication. Middle aged patients are more likely than older patients to want good communication. This may be because older individuals are used to the traditional approach

of the doctor having all the authority in the consultation and being a figure who is above them in the hierarchy of the interaction. None of these studies show counter-intuitive results except for the fact that many patients seem to rate good communication skills over diagnostic ability.

Our doctor’s agenda in the consultation is likely to be more closely linked to understanding the severity of illness and developing a treatment plan. His or her use of common sense language and avoidance of technical or medical jargon can help our understanding significantly. In cancer diagnoses, for example, most of us will have little understanding of terms like ‘median survival’ or ‘good prognosis’.

27

Understanding the differences between the agendas of both patients and practitioners enables us to address each other’s concerns and ensure that we both leave having disclosed and acquired all the information necessary for progress to be made.

28

Hospitalisation and surgery continue to be central features of medical care in developed countries. Some of us will undergo diagnosis and / or therapy and then leave without an overnight stay (outpatients), while others will stay overnight or for several weeks or months (inpatients). The trend in recent years has been for inpatient stays to be as short as possible with an increasing number of procedures now being carried out on an outpatient basis. This is partly driven by cost but also by evidence that shorter hospital

stays are not associated with poorer outcomes.

Although the goal of hospitalisation is to improve health and wellbeing, for the vast majority of us there are a number of negative consequences.

Hospitalisation can be a stressful experience: there is a loss of privacy, independence and control. We can find ourselves in close proximity with other patients we don't know and frequently in intimate contact with healthcare providers, sometimes being

Zone F HOSPITALISATION & SURGERY

29

F

treated as though we are neither mindfully present nor a person. Suddenly we can no longer choose when to eat and sleep, when to read or bathe. We are subsumed by the hospital regime and can become confused by its structure, procedures and terminology.

For some of us, hospital restrictions may be therapeutically desirable and offer freedom from responsibility and an opportunity to focus on recovery. But for others there is concern over the obligations left behind unfulfilled and limited visiting hours, a lack of opportunity to engage with `real' world people and restrictions on TV and radio can be less than desirable. And these restrictions may not be conducive to

recovery. In the absence of external stimuli we may spend more time focusing our attention on symptoms that may or may not contribute to our illness and as a result become more anxious. We may also experience anxiety over the diagnosis, prognosis and the influence of the illness on our life and worry about the treatment regime and the probability of its success. As a consequence we can become distressed and even angry. One researcher has commented that some patients may relieve this anger with “petty acts of mutiny such as making passes at nurses, drinking in one's room, smoking against medical advice and wandering up and down the wards and corridors”.

30

Evidence suggests that high levels of anxiety and stress predict poorer outcomes. This has led to interventions to promote recovery particularly from surgery as well as to reduce anticipatory nausea and vomiting associated with chemotherapy. These interventions are most notably to provide more information and provide cognitive-behavioural therapy. They are effective to varying degrees in reducing the stress associated with hospitalisation and may operate via effects on the immune system and / or by promoting ‘well’ behaviours (or reducing ‘unwell’ or maladaptive behaviours).

31

How we cope and adjust to long-term, chronic illnesses such as asthma and diabetes differs from how we cope with short-term illnesses such as ‘flu’.

Coping methods that we may find to be effective in the short-term, can be ineffective, if not completely inappropriate, to long-term treatment.

Long-term coping and adjustment to illness can be significantly impacted by whether our outlook is generally positive or negative as well as whether we engage with friends and

family for support. The optimists among us tend to interpret situations in a positive light and have a fighting spirit (e.g. “I am determined to beat this disease”) with expectations of favourable results. This has been shown to be associated with improved outcomes and long-term survival among breast cancer patients. On the other hand, pessimists have feelings of hopelessness and helplessness (e.g. “I feel there is nothing I can do to help myself”), associated with poorer outcomes. These differences in outcomes could be related to resistance to stress.

Zone G LONG-TERM CARE

32

G

Studies indicate that optimists are much more resistant than pessimists and concentrate on problem-focused coping aimed at solving the problem and doing something about it. They plan, take direct action and screen out particular activities. They are also more likely to seek social support – the advice and help of friends and others. This can have a significant impact on our recovery and quality of life – a strong social support network can increase adherence to treatment, limit distress, facilitate better coping with stressful events and ultimately increase survival.

In contrast, pessimists tend to give up on goals with which stress interferes and cope with stress in an emotion-focused

way. This can involve denial or positive reinterpretation of events.

Treatment adherence is a critical component of long-term care and involves not only taking the right medicines at the right time but adherence to appointments, programmes that support lifestyle changes and psychosocial interventions.

As few as one in four of us follow medication instructions properly, half of us are likely to discontinue our medication before we are supposed to, and up to one in every three of us make medication errors in ways that may endanger our health. The longer we need to take prescribed medications, the more likely it is that non-adherence will occur. This is compounded

33

when treatment involves multiple aspects including medication, self-monitoring and lifestyle change. In fact, studies have identified 20 factors behind non-adherence, and contrary to popular assumptions, research has failed to demonstrate consistent associations between adherence and personality, gender, education, socio-demographic status, marital status, religion or ethnic background.

It is not surprising that adherence to treatment leads to a better outcome. What is perhaps surprising are studies which show better outcomes for adherers, compared to non-adherers, even when the treatment is a placebo!

34

Although many people may go to hospital or a hospice at the final stage of their disease when their carers can no longer provide the necessary physical or medical care that they need, the majority of care up to that point occurs at home.

Hospices aim to provide an optimal quality of life for us and our families as death approaches, attempting to make us pain-free, minimising our experience of distress, and helping us to maintain as much dignity and control as possible. The intention is also for

us to maintain relationships with our loved ones in a caring and compassionate environment.

Many hospices or nursing homes also aim to create a feeling of independence for us, to alleviate our feeling of being a `burden' upon our carers, encouraging us to continue to live our lives without feeling inhibited.

If we are facing death as a result of a long-standing illness, issues such as ‘a good death’ and ‘dying with dignity’ become crucial.

Zone H TERMINAL CARE

35

H

Solutions must be implemented that will empower us to control the circumstances surrounding our death in a dignified manner.

As well as social, medical and emotional support, those in the final stage of illness often need financial and informational support. Many feel the need to ‘put their life in order’. Some want to be involved in their remembrance services, or set up trust funds, legacies or memorials. Many have spiritual needs irrespective of whether they are a believer, agnostic or an atheist. Many die as they lived, but all want the process to be as psychological and physically comfortable as possible.

The role of family and friends is often crucial in a person’s final days. Death remains a taboo subject and there are often numerous powerful emotions in the last stages of a person's life. One that is most difficult to deal with, is anger. There may be anger at God, their family and the whole injustice of the world. Grieving relatives can suffer similar feelings as well as the anxiety and depression of grief. Hence the importance of professional help.

Research has shown that conventional therapies have limited application to the sick and the dying. Much like healthcare provided throughout one’s life, effective communication with the patient and family are critical. The provision of information,

36

predictions and prognosis can all have a significant influence on future behaviour and potentially on treatment and illness outcomes. From the patient and the family's perspective, difficult questions need to be asked, each requiring sensitivity and honesty. From that of the health professional, a judgment call is required regarding the capability of people to understand and manage the information they are requesting.

37

38

20 big ideas in health to connect with 2020

39

Personal futuring

40

1“ ”

BY 2020 ADVANCED GENETIC PROFILING WILL BE COMMONPLACE

Testing for cholesterol, blood sugar and birth defects is already the norm. However, we are now on the brink of a major step forward on this evolutionary journey: by 2020 advanced genetic profiling will be commonplace. And while cures may still elude us, identification of the future diseases for which we are at risk will allow us to screen for these conditions specifically and adopt preventative lifestyle changes and treatment regimes. Health insurers, genetic profiling service providers and diagnostics manufacturers will flood our personal devices offering incentives including conditional access to latest treatments and lower premiums.

Outdoor electronic billboards will promote the benefits of preventive intervention comparing those who have been

41

profiled and have made decisions accordingly, and those who haven't. And of course, our personal genetic profiles will be integrated into our ‘cloud-based’ electronic health histories (formerly known as electronic health records).

As well as support from friends and family, the role of health professionals will be pivotal in helping us make sense of complex information about our future to understand relative risk, the benefits of screening and early intervention. We will see a new breed of patient groups, with health professional input, dedicated to specific genetic aberrations, their tests and early interventions. The focus will be on the

rational and emotional benefits of earliest possible intervention.

The more we know about disease the better our prediction will be about the future of our own and others health and longevity. However, because (nearly) all diseases are

determined by multiple factors no prediction or prognosis is ever completely error free: we speak in terms of probabilities. We inherit potential not certainty and we can intervene at

all stages so we will still live with uncertainty.

Individual reactions to our own health vary greatly: some of us repress and ignore advice and warning signs;

others act immediately. Some of us react from our hearts;

42

others their head. Some societies encourage agency, mastery and control: others help people accept their fate.

Relatively few people will discover that they are predisposed to incurable, degenerative diseases. Testing will indicate conditions that are potentially manageable through early lifestyle intervention, and possibly the introduction of preventative medication and most people will simply do what they can to live as well as possible for as long as possible.

43

Pocket health check

44

2“ ”

THIS WILL MAKE IT POSSIBLE TO RECOGNISE DISEASE ONSET EVEN EARLIER

Medical diagnostics are rapidly evolving and we are already seeing faster and earlier recognition of disease driven by much higher levels of diagnostic sensitivity. Continuous advances in ‘laboratory miniaturisation’ such as DNA microarray and lab-on-a-chip systems for example, will open the doors to tests currently conducted in a laboratory, being carried out at home using our PMFDs. This will make it possible to recognise disease onset even earlier and results will be available within minutes or hours rather than days or weeks, more cost effectively with significantly more accuracy, in more people. Increasingly high resolution cameras in our 2020 PMFDs, supported by imaging algorithms will also facilitate remote observational screening at home, with or without a physician on the other side of the lens.

45

The challenge in 2020 will continue to be about the willingness of people to participate in screening. While ‘health rewards’ and incentives may help, the big carrot will be the prospect of earlier intervention leading to better disease management and in some cases a cure as opposed to curtailment.

Everybody accepts that prevention is better than cure, but just as some people don’t want to know the sex of their unborn child, some prefer not to know the future of their own health, however cheap, easy and convenient it is to monitor. Screening allows for better management but it is not always totally accurate and press stories about false positives

and negatives have a big impact on those volunteering. Lots of factors determine the frequency with which a person attends for screening or uses a pocket measure: their

personality, health beliefs, medical history, friends and family. As screening becomes more common, cheaper

and more reliable it will be the norm rather than the exception. It may even become mandatory

in certain countries or particular organisations to be screened for very specific illnesses, which will cause political uproar. Importantly, if we can do the screening ourselves we can

keep the results confidential, thus reducing fear of embarrassment and social stigma.

46

It pays to be healthy

47

ADVERTISERS WILL KNOW AN INDIVIDUAL CONSUMER’S BEHAVIOUR ABSOLUTELY AND IN EXHAUSTIVE DETAIL3 “

”

Cross-analysis of people's lifestyle behaviours offers insights and opportunities to promote healthy lifestyle options. Partnerships between financial institutions, health insurers and pharmaceutical companies for example opens up the possibility of tracking users and encouraging them to make decisions that will benefit both the individual and companies alike.

Welcome to a world where customer data is instantly available and deals and money saving promotions can be targeted accordingly. In this world, health-promoting options can be offered. And, the more health conscious options an individual makes, the more rewards they receive.

48

Knowing real world behavioural patterns of consumers and being able to tailor promotional messaging in real time is the nirvana of the marketing industry. A future of tracking individuals’ locations and activities through facial recognition, GPS and retina / fingerprint scanning will open the door to highly targeted advertising.

Advertisers will know an individual consumer’s behaviour absolutely and in exhaustive detail. This information will be analysed to deliver relevant and targeted messaging via a range of digital media.

People know about but don’t always follow guidelines (e.g. calorie intake, exercise, alcohol intake), often because they are unrealistic and unachievable. People can be incentivised

to be healthier e.g. pounds for pounds, in taxes; but our responses to incentives differ. Extrinsic motivation (by objective rewards) can backfire: intrinsic motivation (for the love of the activity) is always better. Targeted marketing has always been carried out by manufacturers and advertisers. We have used psychographics to segment people according to their lifestyle and there is much more data available now to help us do this. Health messaging can be targeted to sound more positive, i.e. healthy hedonism, but the problem for most societies is that it is the middle-class, educated and more healthy people who attend to the messages, follow them, and pay for them whilst most of those who need to follow them, do not.

49

Infectious disease swarms

50

THE BENEFITS OF TRADING THEIR PERSONAL DATA FOR TECHNOLOGICALLY-ENHANCED PROTECTION

4 “”

We have already entered an age of location-based services, GPS tracking and various topographical-based ‘mashups’ (data combinations). And, as Google FluTrends highlights, using vast amounts of individual data to detect patterns has massive potential for mapping infectious disease outbreaks.

In 2020, people’s PMFDs (personal multi-functional devices) will contain their health & lifestyle histories, enabling authorities to track their behaviours and identify the potential spread of disease. Media hype can cause a frenzy of anxiety about the potential dangers of infectious disease, as we have seen with SARS, Swine Flu and Avian Flu. The ability to accurately map and identify outbreaks will be invaluable in

51

either allaying or justifying public concern. Media-driven mass panic seen today will be mitigated to a degree, by the tracking technologies of 2020. But all of this will only happen if people understand the benefits of trading their personal data for technologically-enhanced protection. This will have to be addressed through public education campaigns that people believe and trust. In 2020 such campaigns will be ‘authored’ by co-operatives that will most likely be driven by highly influential social groups as well as leading consumer brands.

Increased levels of information for individuals and their families should help prevent

exposure to potential illness and provide peace of mind. Awareness of an infectious disease outbreak at the children's school, a potential holiday destination, the local sports centre or the local restaurant could dramatically impact an individual's decision-making. Stirred up by the media this may

lead to mass panics, which politicians will have to address.

However this also leads to a phenomenon known as ‘modern health worries’: concerns about how aspects of modernity influence health such as contamination of food or various types of environmental pollution. People also worry about bio-terrorism and genetically modified foods;

52

about cell phone and overhead cables. Although knowledge is power, there are two issues to be managed here: first, when you're powerless to adjust behaviour even when knowledge indicates you should; second, if information lacks perspective and leads to forms of mass hysteria.

53

One statin burger coming up!

54

INDULGENCES OF 2020 WILL BE CLINICALLY PROVEN TO BE GOOD FOR US...

5“

”

Restaurants and other food service companies are positioning themselves more and more as lower-fat, better-tasting, calorie-reducing health crusaders for the masses. We all know that closer inspection of the menu of ingredients for some, might argue otherwise. But by 2020 much of this will have changed. The food industry will have embraced the regulatory challenges the pharmaceutical industry currently face and will incorporate clinically proven health benefits in their brands. And through alliance and / or acquisition, the pharmaceutical industry will be exploring foods and beverages as vehicles for delivering preventive medication so that selected indulgences of 2020 will be clinically proven to be good for us both physiologically and psychologically. When stepping into a multi-national fast food chain or arranging the weekly shop,

55

online people's choices will be proactively influenced by their dietary and medical histories as well as their future health requirements.

Affecting behaviour change among individuals who either do not understand or care about the impact bad lifestyle decisions have on their health is one of the most difficult issues facing the healthcare industry. Many factors are involved as we see in the models of behavioural medicine. Making health decisions

easier for people and rewarding them for good behaviour may provide a way to

reach ‘hard-to-convert’ people. Thus it has been proposed to pay people to give up smoking or lose weight for example. Ultimately, it is hoped this saves money for the healthcare funders. Providing people with more information about their diet and health state is a good way for individuals to monitor and consequently change their

behaviour. Funders can attempt all sorts of strategies to encourage and

56

discourage various forms of behaviour. This could include legislation banning advertising for certain extremely unhealthy products and providing tax relief for food manufacturers and retailers who interface with individuals’ health records and respond with tailored, health-supporting, products and services.

57

It’s what’s inside that counts

58

..MONITOR OUR BODIES’ VITAL READINGS VIA MINIATURE.. IMPLANTS

6 “”

Continual measurement of the body’s vital signs is crucial to effective management of illness (or potential illness). As some people with heart conditions know, technology already exists that can monitor the heart and even shock it back into life should anything go awry.

By 2020 we will be able to monitor our bodies' vital readings via a miniature RFID (Radio Frequency Identification) implant. Data will be captured, transmitted and stored within our ‘cloud-based’ electronic health histories and just as with today's home security systems, different packages will be available for different levels of observation to identify asymptomatic changes in the body that would otherwise go unnoticed. This technology will be used to create instant

59

medical alerts, monitor adherence, measure the effectiveness of our medication and create data for broader research methodology, taking self regulation to a whole new level.

We have long known the benefit of monitoring our physiology. The whole concept of biofeedback has been very popular and successful for helping people monitor their stress levels and reactions. We like to receive feedback on our progress and moreover, feedback changes behaviour. However, it is more effective if it is specific, reliable, easy to access and easy to interpret.

The question for many people is what the feedback means and what they can do about it: even if an individual knows that their blood pressure is suddenly up, they may not necessarily understand why, and more importantly, what they should do.

And as we have seen with smartphones, it may become a fashion statement to show off your monitoring device, in which case social approval for being health conscious could help people focus on how they should respond. Saying this, many of the responses in the future are likely to be automatically generated.

60

Talking medicine cabinet

61

..THE BATHROOM CABINET.. WILL TAKE ON A WHOLE NEW ROLE

7 “”

In addition to our PMFDs (personal multi-functional devices), the bathroom cabinet (and other digital display devices of the future) will take on a whole new role. Feedback loops could provide them with information to advise us on what we should do about any signs and symptoms. Likewise, the fridge could advise us on what to eat depending on health status.

Information and action alerts will be created in part by generic clinical algorithms. But they will also be fine tuned, or personalised, based on self-selected and automatically generated (anonymous) recommendations from family, friends and colleagues (lay referral system). We will be helping one another to help ourselves.

62

Continual communication of health messaging for some, could be very supportive, acting as an aide-memoire for their medication especially if they suffer from conditions requiring continual monitoring and intervention such as diabetes.

It may seem like having a ‘live-in’ doctor, which may be particularly useful when dealing with an ‘embarrassing issue’. Devices such as ‘SatNav’ mean that people have become used to machines talking to them

although we do like to choose the voice: male versus female, nationality of accent, tone (friendly versus strict).

But the continual bombardment of messaging and intrusion into everyday life could become

tiresome and / or overwhelming. It could be like ‘big brother’ or ‘little brother’ is watching us, if not managed carefully. Digital display devices will give directions

or suggestions for action, rather than simply provide information, and these will need to be followed correctly, to avoid potentially serious

implications. It will be very important to get

63

the tone and timing right if people are to respond positively to the recommended courses of actions, provided by the technology of tomorrow.

64

The age of auto-triage

65

DIAGNOSTIC ALGORITHMS WILL INTERACT WITH A PERSON’S... ELECTRONIC HEALTH HISTORY

8“

”

For many of us, once we have decided we need to respond to symptoms, our engagement with healthcare services can be associated with waiting and worrying. As anyone who has visited their local Emergency Room in the past few years can tell you, triage resources are strained and the pre-screening of patients takes longer than most would consider necessary. In 2020 the use of technology will counter this. Upon arrival, touch-screen questionnaires will be individually tailored based on our existing electronic health histories. That is, of course, if this information hasn't already been automatically transmitted from home or in the car beforehand.

66

Triage investigation and analysis will be conducted behind the scenes, without the need for human interaction. Diagnostic algorithms will interact with a person’s ‘cloud-based’ electronic health history (EHH), genetic profile and feelings to enable instant assessment and, in turn, faster assignment of their treatment priority.

Many of us have learnt very happily to do things with machines that previously would have been done by people: e.g. check-out at supermarkets, check-in at airports. It isperceived as quick and reliable. And the idea of prioritising themost needy is generally accepted. But it is a different matterfor many when considering who has access to their medicaldata: their doctor, their family, their employer and most of all

themselves. Concerns about the security of these data will need to be allayed.

The idea that people could be automatically ‘checked-in’ to a virtual clinician when at home, or anywhere for that matter is attractive except that health issues are highly emotional. Some people will always prefer to have the emotional reassurance of a doctor that they could both see and hear right from the very beginning, as opposed to interaction with a machine.

67

Get a check-up before you check-out

68

EVERY ITEM THAT IS PURCHASED WILL HAVE A ‘HEALTH VALUE’ ATTACHED TO IT

9 “”

Supermarkets are so much more than a place to do your weekly shop. The list of offerings for the consumer in just one building is mindboggling – petrol, electronics, mobile phones, insurance, credit cards, travel agents, restaurants, clothing, pharmacy, photo, furniture… oh, and you can even buy your weekly groceries. And, this is all available 24 hours a day.

As such, supermarkets’ pharmacy offering is sure to increase and expand. In 2020, supermarkets will not only fulfil prescriptions and sell over the counter (OTC) remedies, they will become comprehensive centres of health services.

This will be driven by what we buy, what we eat and what we do. Every item that is purchased will have a ‘health value’ attached to it and this data will be collected at the point of

69

sale and merged with activity and food consumption data from our personal multifunction devices (enabled by advances in visual recognition).

As such, the retailing giants of 2020 will proactively and pre-emptively engage us in self-health consumption, all at the right price of course.

We are used to frequent traveller miles and other points systems and if the incentives are right, there is no reason why people wouldn’t respond to health points. For example we may get more points for `lower fat' versions of some products. Given human nature, if these did become a reality, some

people may start buying them for others rather than themselves: knowing whether people actually consume / use the products they buy will be essential.

There are already debates about large corporations having more power over people's

lives, being motivated by profit, and what they may do with ‘personal information’. In order for such organisations to act as ‘health guardians’, new levels of trust will have to be built, communicated and maintained.

70

Patients really like me

71

... PATIENT CO-OPERATIVES WILL BE PRESENT THEMSELVES AS LIFESTYLE BRANDS

10“

”

PatientsLikeMe.com – a social networking health site that enables its members to share treatment and symptom information in order to track and to learn from real-world outcomes – is the flagship of the online movement for patients to share information and experiences.

In 2020 a multitude of patient co-operatives will present themselves as lifestyle brands, competing with one another for our personal health experiences and data. Some co-operatives will be open to everyone with the same disease, while others will have specific membership criteria for example based on genetic profile, illness attitude and experience: not just any patients with the same disease, ‘patients really like me’.

72

These co-operatives will compete to sell our data (in an anonymous format) to pharmaceutical and other healthcare companies to enhance member benefits and their own brand profile. Mass data collection via RFID (radio frequency identification) devices and PMFDs (personal multi-functional devices) will provide information that will dramatically increase our understanding of variations between, and within, diseases and their patient populations. It will also aid significant advancements in medical care by revolutionising clinical research in prescription and OTC medicine with an overall shift in power towards patients.

People who are interested in helping others change their health-related behaviours say the same

thing: “Make a realistic plan, start small, change one behaviour at a time, but most of all, involve a ‘buddy’ and ask for support from those who care about you.”

Patient support groups have grown exponentially over the past decade. They have different functions, dependent largely on their membership: they can have a political function to lobby authorities; they can have an educational function to help others understand their illness and be more sympathetic to sufferers and their families.

The most important function of these groups is to provide emotional, informational, technical and even financial support to others with the same problem. This has always been known to be a very powerful factor in healing and helping people feel

73

that they are really understood. Groups that harness digital technology to progress beyond offering contacts ‘similar to me’ to those ‘really like me’ will help people regain a positive social identity, reducing the feeling of isolation and minority status.

74

You have to see it to believe it

75

...COMPUTER-GENERATED VIDEO FEATURING THE PATIENT AS THE ‘STAR’...

11“ ”

Communicating the impact of a diagnosed disease can be challenging and patients often underestimate their condition. Diabetes, for example, can often be asymptomatic but if uncontrolled can lead to severe complications such as cardiovascular disease, blindness and amputations.

In 2020, patients are likely to walk away from their doctor's office (or close their browser window) and within a very short time be able to view a detailed description of the impact of their condition presented as a video documentary. Physicians will have instructed software to access large databases

76

to quickly assemble a portfolio of information that provides patients with a ‘commonsense understanding’ of their condition. The use of computer-generated video featuring the patient as the ‘star’ will depict outcomes for them with and without lifestyle and medical interventions.

Seeing their future selves living out their predicted lifestyle, vividly on screen, will help drive home the gravitas of their situation and affect behaviour.

Although we remember best what we have read, rather than heard or seen, the power of imagery can have a very dramatic effect on behaviour. Using words and pictures together to help people understand the impact of their disease and its potential future consequences can drive patients to better

make decisions about their health. It can reduce the ‘it cannot / will not happen to me’ syndrome.

Beyond static visualisation, video can present dramatic emotional drivers aimed at behaviour change. Charities have always known this. The challenge will be to use digital technology to bring to life future scenarios that are perceived to be real, not make-believe, that empower rather than frighten, so that people will actually apply the message and adopt recommended health behaviours.

77

Home and (far) away

78

...MINIMALLY INVASIVE AND NON-INVASIVE PROCEDURES AT HOME...

12 “ ”

Overburden on staff, diagnostic services, hospital beds and other resources indicate a need for a dramatic change in the way healthcare systems manage patients. Given the increasing range of self-assessment and self-treatment technologies, an increasing amount of specialist consultation and hospital care may soon be possible at home.

The technology of 2020 – that allows continual update of electronic health histories, virtual consultations, easier analysis of the body's vital signs and adherence tracking – will enable healthcare professionals to treat patients remotely. We will see a growth in community nursing which will support minimally invasive and non-invasive procedures at home: already camera-in-a-pill technology is replacing traditional

79

approaches to in-hospital endoscopy and developments in this area are likely to enable more examinations and interventions at home, perhaps even without assistive nursing support.

Hospitals have the staff and technology to cope well with emergencies and unexpected events, but the institutional nature of these facilities can mean that various groups are not well catered for: some people particularly dislike mixed wards, or restrictions on various religious practices.

For most people home is where the heart and health is. We say we

go home to retreat to a place of familiarity, security and support. And home

births are popular despite certain difficulties. People have always wanted home visits by their doctor

particularly in dealing with very personal, potentially embarrassing issues. This is because hospitals can be depressing places for some people: the clinical environment, the impersonal nature of things; the institutional rules and regulations, the changes in personal habits.

Hospitals will need to embrace technology holistically. While emergency and critical care will continue to be served best in

80

these environments where wide-ranging expertise is immediately on hand, a thorough re-appraisal of the provision of non-critical care will deliver cost-efficiencies and desired health outcomes at home. For this to happen, tomorrow's doctors will need to be trained now on how to interact with technology itself and with their patients via this technology.

81

Dominelle Bay: Welcome to Dominican Republic’s premier women’s health resort

82

...SURGICAL INTERVENTION WITHIN OASES OF PSYCHOLOGICAL NOURISHMENT

13 “”

Some consider healthcare in the developed world to be overpriced and under-resourced. Many health systems around the world struggle to reduce waiting lists for important treatment and surgery. Therefore patients, and some providers, are increasingly looking for alternative methods of treatment.

We've all read of people going to developing nations for cheaper healthcare and receiving high quality and efficient treatment. This trend is set to continue and by 2020 could be considered part of a normal treatment routine. Several global

health providers will have partnered with or acquired leading hotel chains to target premium patients with offers of surgical

intervention within oases of psychological nourishment. Earlier detection of disease will broaden the window for effective surgical intervention making advance planning a reality. For some patients, hospital stays will actually become longer as they take the opportunity to recharge their minds, away from the stresses of day-to-day life. Still in intimate contact with their family & friends through state-

of-the-art technology, they will actually get better and feel better more quickly.

83

Healing and recovery are as much about the mind as the body: a healthy body is found in a healthy mind. Exotic locations that incorporate relaxation and pampering may better facilitate physical healing and enterprises that provide all sorts of ‘alternative’ therapies may have particularly powerful placebo effects.

Health tourism is driven by three things: waiting lists, costs of treatment and individual wealth.

Wealthier people from the developing world come to the developed for diagnosis and specialist treatments, while many in the developed world go to developing world countries for things like plastic surgery or advanced dentistry.

Such inequalities associated with health tourism are unlikely to disappear. But broad adoption should not only have a positive impact on the individual but release valuable resources for those

unable to afford it.

84

Grow your own body

85

...WE ONLY HAVE TO REFLECT ON WHAT AMPHIBIANS ARE CAPABLE OF

14“ ”

Over recent years the ability for scientists to artificially grow cells, tissue and bone by using existing human samples has brought both praise and scepticism in equal measure.

As this area of research continues to move forward, the potential for use in human medicine is almost overwhelming. Between now and 2020 we will have moved beyond the fields of skin and bone replacement to regeneration in life-threatening and life-restricting diseases including cancer, cardiac infarcts, diabetes, kidney failure, liver failure and neurodegenerative illnesses.

The prospect of amputees, burn victims, diabetics, and even those seeking cosmetic improvements being able to amend their bodies to any desired form, is both frightening and

86

exciting. Numerous processes still have to be perfected to reach the goal of breeding whole organs or parts of the human body, but we only have to reflect on what amphibians are capable of, to consider this a probability rather than a mere possibility.

Organ donation is a very tricky issue and one that can carry a lot of anxiety for the donor, the recipient and the families of all those concerned. Furthermore, there are many cultural and religious issues concerning organ donation and transplantation.

For people in situations where a ‘required match’ could have been found it will eradicate the problems of rejection and the side effects associated with immunosuppressive

therapy. But more significantly, it could mean that fewer people have to suffer from a shortage of donor organs and tissues.

Tissue and organ regeneration has the potential to eliminate many of the anxieties and issues

currently associated with donation and transplantation, but will introduce new worries of its own among patients and their families. Healthcare

professionals will of course endeavour to manage these, but initially, won’t have a significant track record to draw from.

87

Robodocs

88

...HUMAN JUDGEMENT AND INVOLVEMENT.. WILL BECOME MINIMAL

15“ ”

Surgeons increasingly rely on modern technology and advanced macro and micro anatomical imaging to augment their skills, thereby improving patient outcomes. Utilisation of technology can be lifesaving and can alleviate certain stresses and concerns for the surgical team, the patient and the healthcare system.

Robotics will develop to the point where the need for human judgement and involvement in many routine procedures will become minimal. Some hospitals and clinics will establish bespoke facilities focussing on high throughput, highly automated imaging and minimally invasive, robotic surgical interventions. The lure of automation and associated cost

89

savings will change the mix of professional assistance in favour of nursing support.

While patients won’t quite be performing basic surgical procedures at home by 2020, we will see a reduction, but not eradication, of human intervention in many cases.

Today, we drive cars designed by robots, we ‘fly by wire’ and we travel in trains that do not have drivers. Yet despite the sophistication of machines many people want them monitored by humans so that automated decisions can be over-ridden,

even though man is liable to make many systematic errors however bright

and well trained.

Already, robotic-assisted surgical procedures have been shown to reduce the duration of

hospital stays and patient surveys suggest that this approach is chosen because of greater expectations of decreased morbidity, improved outcomes and less pain.

But whilst medical care is about accurate diagnosis and effective treatment, which computers and robots are increasingly capable of, it is also about empathy and understanding – the emotional ‘add on’ that sets humans apart. Man will always have a role to play in healthcare

90

provision. In the specific case of robotic intervention, identifying and meeting the needs of patients who need support through tailored preoperative communication, family counselling and postoperative support groups will become key themes in the future.

91

One pill for every ill

92

...UNIQUELY PERSONALISED PRESCRIPTIONS.. DELIVERED TO OUR DOOR, OVERNIGHT

16 “ ”

Many people with multiple conditions and chronic disease have to take numerous pills to manage their health. Pharmaceutical companies have spent a significant portion of R&D funds researching combinations of drugs that are commonly taken concurrently as part of a treatment regime. The aim is to reduce the pill burden for individuals so that they may only have to take one pill daily, which in turn, can help increase adherence and improve outcomes.

But, the way our bodies process drugs can vary from one individual to another. By 2020, the days of `standard' prescriptions being fulfilled by a local pharmacist will be increasingly replaced by personalised polypharmacy, which will be precisely tailored to our genetic profile and how we as

93

individuals (not population averages), metabolise drugs differently. Repeat prescriptions will be automatically generated and adjusted according to our response and adherence data, unless a physician intervenes of course. This could be centrally processed at regional fulfilment centres and our uniquely personalised prescriptions, delivered to our door, overnight.

Non-adherence, that can be exacerbated by a high daily pill burden, causes

prolonged suffering, extra visits to the doctor, longer recovery time and avoidable hospitalisation – it is costly to both the patient and the

profession.

Suboptimal dosage can also cause prolonged suffering and present an

unnecessary demand on the healthcare system.

Tailoring dosage, making it easier for the patient to take their prescribed medication will help, but this is not the only factor

94

of importance in encouraging adherence. People tend to follow their doctors’ orders more when they believe it is the appropriate course; they understand and are able to undertake the actions; they are not impeded in their course of action and they are able to monitor their progress. Personalised polypharmacy will need to be supported by personalised digital interventions that address these factors to realise its full potential

95

Intelligent meds

96

THIS TECHNOLOGY WILL NOT IN ITSELF IMPROVE ADHERENCE

17 “ ”

We already have pills that contain a microchip to check information about the patient’s body. The ‘chip-in-a-pill’ system takes measurements from within the body. When the pill comes into contact with stomach acid, it generates an electronic signal that communicates with a body patch. This data is then remotely forwarded to a central database and is accessible via mobile devices.

This technology will become cheaper and more feasible over the next decade, enabling enormous advances in monitoring. But it will not in itself improve adherence. By 2020 leaders in this and similar technologies will also have invested heavily in patient segmentation and behavioural medicine. They will be providing PMFD (personal multi-

97

functional device) programmes, addressing the 20 factors affecting adherence, based on the collated behaviours and experiences of patients at similar life stages, with similar lifestyles and similar health attitudes.

Currently there are various ways of assessing whether patients are taking their medication, from pill counts using

mechanical devices through to blood and urine tests. But these can be both inaccurate and costly respectively. We also know that between one third and a half of patients do not comply with medical advice when it comes to taking medicine, but when questioned, they often say they do so in order to please their doctor: reported behaviour differs from their actual behaviour.

Knowing a patient's adherence precisely will require a change in the nature of the ‘conversations’ healthcare institutions and healthcare professionals have with their patients. There will be a need to identify and understand individual reasons for non-adherence in a tone that is sympathetic not condescending. This in turn implies a focus on the ‘language’ of the interaction that will best support future behavioural change. And there will be a need to follow this with behavioural counselling to address these reasons. Not all healthcare professionals are adequately equipped in this, nor are healthcare administrators.

98

A game of life and death

99

...GAMES WILL HAVE BEEN CREATED... INCORPORATING REAL LIFE PATIENT DATA AND BEHAVIOUR18

“”

Throughout our entire lives we learn by playing, and games can be the most enjoyable (and some might argue, the most effective) way of teaching good behaviour, structure and knowledge.

To that end, games can increase adherence and teach people about diseases. In fact, this has already been proven through a number of studies.

As evidenced by social gaming and new easier-to-use gaming consoles, games are an activity for the masses. This trend is set to continue and fun, educational gaming will be tailored to specific patient populations and at-risk groups.

By 2020 games will have been created for many chronic disease communities incorporating real life patient data and

100

behaviour. Patients within these communities will bond with and learn from one another through social gameplay. They will devise strategies as part of this gameplay and if they live these out in real life they will achieve higher status. Leading players achieving expert patient status will gain additional credits for coaching others to play the game better.

And so the line between patients’ virtual worlds and real lives will blur as online activity favourably impacts offline behaviour and health outcomes.

Gameplay teaches about knowledge and dexterity and reaction times. It also teaches about others and how we compare to others. We know that electronic games can be addictive, provide excitement, and a sense of achievement.

Thus, through these mechanisms, they can provide feedback on one's progress. They can allow people to enter a fantasy world and to experiment: they can allow

for automated, unconscious

101

behaviour change and learning.

Saying this, gaming is unfortunately burdened with misconceptions that aren't conducive to its deployment in healthcare e.g. ‘computer games are mostly played by young men’; ‘virtual worlds are not for serious matters’.

The challenge with gaming therefore, is perhaps less about acceptance by patients and more about acceptance by the healthcare professionals. The latter is important not only in terms of deploying gaming in healthcare, but in developing meaningful healthcare games that will require collaboration between experts in health and experts in gameplay.

102

Feel better with designer genes

103

GENETIC SCREENING OF SOMATIC MUTATIONS IN TUMOURS WILL BECOME A STANDARD DIAGNOSTIC TEST...

19“

”

Genetic testing and modification

provides enormous potential for the medical community. Because

of its accuracy, gene therapy in cancer treatment specifically destroys tumour cells without

damaging normal, healthy tissue. Improvements in DNA sequencing technology will mean that genetic

screening of somatic mutations in tumours will become a standard diagnostic test, thus enabling tailored, targeted therapy to be administered. In non-cancerous diseases, somatic gene therapy works by introducing one or more genes into the diseased cells to inactivate or replace a mutated gene causing the disease. Unfortunately the effects

of somatic gene therapy are short-lived because most cells die and are replaced by new ones, with the mutated gene, which means repeated treatments are necessary to maintain therapeutic effect.

The potential of gene therapy is enormous, but the results to date are somewhat limited. By 2020, not only will we be able to identify many of the genetic faults and deficiencies behind today’s life-threatening and life-limiting diseases, but gene therapies will also be available to deliver ‘patient-friendly’ treatments.

The more we understand medical genetics the greater the opportunity to identify and correct errors that create disease. Gene therapy can offer hope where none existed before, but it

104

is important that patients and their families understand what is wrong with their genes and the consequences of electing to have or not have gene therapy. Long-term, repeat treatments can be very stressful for the individual primarily, but also for the family: they can mean time off work, hospital visits, and stress.

With gene therapy, there is the worry of side-effects (as with any treatment) and the possible dangers associated with any experimental therapy. But already there is also great optimism. All of this needs to be carefully managed so that people’s expectations are realistic. This means understanding probabilities and the likelihood of success or failure, and we know how challenging communication of these can be.

105

The power of the mind

106

USING THE POWER OF THEIR THOUGHTS...

20“ ”

As the power of modern computing grows alongside our understanding of the human brain, we are on the brink of seeing technology transform terminal care. The development of brain-computer interfaces is already taking gaming to the next level by enabling players to interact by the power of thought. Similarly, ‘The Multimodal Brain Orchestra’ has demonstrated how a `conductor' can control an orchestra by thought alone.

This technology holds great promise for the development of interactive care environments where terminally ill patients with limited mobility or strength have the option to control their surroundings, easily interact with others, both near and far away and provide themselves with mental stimulation. In 2020, brain-computer interfaces will be used to allow patients to control a

107

range of interactive devices from their bed. Using the power of their thoughts they will be able to select movies, communicate with their friends and family, control their personal finances and even take a relaxing simulated break abroad. Clearly, terminal care may always be a daunting experience, however, this technology has the potential to give patients greater control and peace of mind.

There is nothing quite as depressing for people as to lose control and feel helplessly dependent on other people, particularly strangers. This is particularly difficult if one is in pain or nearing the end of life. Worse is the problem of not being able to communicate clearly ones hopes, wishes and thoughts to family and friends.

People ‘medicate’ with music and with memories. We know the power of social support to improve a person's morale which improves all aspects of their physical state. Work with quadraplegics has shown how providing some way of communicating makes all the difference to the quality of their lives, and those looking after them.

Most want to talk not only to friends and families, but also to professionals. People in terminal care want to get ‘their affairs in order’. This involves not only messages to loved ones, but also monetary and related issues they want to resolve before they die. Things need to be said, and clearly. Also, particularly with family, there may be emotional issues and long ignored

108

problems that many are most eager to settle. Giving them a way of doing this can substantially improve their quality of life.

109

Conceived & created by:David Davenport-Firth, Enrique Alda, James Robertson, John Green, Sarah Gordon,Claudia Calvo, Francis Martinez, José M Gallego

© 2010 Ogilvy CommonHealth Worldwide© 2014 iBook Edition