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ForewordDiscussion of health often focuses on the financialcost of healthcare. Far from a cost, our health is ourprimary asset, as individuals, communities and as anation. Maintaining ‘good health’ and preventing‘ill-health’ is an investment for the future. This isso important that we need to measure and trackhealth in our society. After all, as Peter Drucker said,“What gets measured gets managed.”I look at the future health of England’s populationin this, my tenth, annual report. As the NHS hasbeen developing its own 10-year plan, I look furtherahead. I wanted this report to take an aspirationalview of what health could and should look like in2040 if we commit to it being our nation’s primaryasset.Every part of the health system has a role to play increating a healthier and fairer future. The fortunatetruth is that we already know how to make fantasticimprovements and prepare for better health that is‘within our reach’. The green shoots of a brighterfuture are already visible in some parts of our healthsystem. Now we need to develop, plan and scale,harnessing technology (including wearables and AI)to support this.We need to develop our environment to make thehealthy choice the easy choice, thus promotingour health, our happiness and our economy whilstpreventing disease.I hope this report inspires all readers to understandthat we can achieve better health in England in2040 – this can be our shared vision, with each ofus delivering our part, in our different ways.Prof Dame Sally C DaviesAnnual Report of the Chief Medical Officer, 2018 Health 2040 – Better Health Within Reach Foreword page 1

Annual Report of the Chief Medical Officer, 2018 Health 2040 – Better Health Within Reach Foreword page 2

Editors and authorsAnnual Report of the Chief Medical Officer, 2018 Health 2040 – Better Health Within Reach Editors and authors page 3

Editors and authorsThis report could not have been produced without thegenerous input of the following people.Editor-in-ChiefJonathan Pearson-Stuttard, Imperial College LondonProject Manager and EditorOrla Murphy, Department of Health and Social CareChapter AuthorsChapter 1Chief Medical Officer’s summaryChapter lead and authorSally C Davies, Chief Medical OfficerChapter 2Health and economic outcomesChapter 6DemographyChapter leadLucinda Hiam, London School of Hygiene and TropicalMedicineChapter authorsLucinda Hiam, London School of Hygiene and TropicalMedicineMartin McKee, London School of Hygiene and TropicalMedicineDanny Dorling, University of OxfordChapter 7MultimorbidityChapter leadChris Whitty, Department of Health and Social Care andLondon School of Hygiene and Tropical MedicineChapter authorsPaul Johnson, Institute for Fiscal StudiesChapter authorsChris Whitty, Department of Health and Social Care andLondon School of Hygiene and Tropical MedicineGeorge Stoye, Institute for Fiscal StudiesAlexandra Lee, Department of Health and Social CareDavid Sturrock, Institute for Fiscal StudiesChapter 3The local health environmentChapter leadTim Elwell-Sutton, The Health FoundationChapter authorsTim Elwell-Sutton, The Health FoundationLouise Marshall, The Health FoundationDavid Finch, The Health FoundationJo Bibby, The Health FoundationChapter 4Social healthChapter lead and authorTom Kibasi, Institute for Public Policy ResearchChapter 52040?How will health be experienced inChapter leadMartin Stewart-Weeks, Public Purpose Pty LtdChapter authorsMartin Stewart-Weeks, Public Purpose Pty LtdJunaid Bajwa, MSD and Imperial College LondonMobasher Butt, Sloane Medical Practice and GP at Hand (NHS)and Babylon Healthcare LtdSpecial section – Mental health disorderSection AuthorAnto Ingrassia, Children and Young People’s HealthPartnership, Guy’s And St Thomas’ NHS Foundation TrustChapter 8  Changing behaviour for a healthierpopulationChapter leadTheresa M Marteau, Behaviour and Health Research Unit,University of CambridgeChapter authorsJames G McGowan, THIS Institute (The HealthcareImprovement Studies Institute), University of CambridgeMark Petticrew, London School of Hygiene and TropicalMedicineHarry Rutter, Department of Social and Policy Sciences,University of BathJonathan Pearson-Stuttard, Department of Health and SocialCare and Imperial College LondonMartin White, University of Cambridge and Public HealthResearch Programme, NIHR and UK Society for BehaviouralMedicineTheresa M Marteau, Behaviour and Health Research Unit,University of CambridgeAnnual Report of the Chief Medical Officer, 2018 Health 2040 – Better Health Within Reach Editors and authors page 4

Editors and authorsChapter 9  Health inequalities – a challengeto current health policyChapter 11  Emerging technologies –population scale impactsChapter leadMajid Ezzati, Department of Epidemiology and Biostatistics,School of Public Health, Imperial College London andMRC‑PHE Centre for Environment and Health, ImperialCollege London and WHO Collaborating Centre on NCDSurveillance and Epidemiology, Imperial College LondonChapter lead and authorMaurizio Vecchione, Global Good and Research, IntellectualVenturesChapter authorsJames Bennett, Department of Epidemiology andBiostatistics, School of Public Health, Imperial College Londonand MRC-PHE Centre for Environment and Health, ImperialCollege LondonChapter leadDominic King, DeepMind and Imperial College LondonJonathan Pearson-Stuttard, Department of Epidemiologyand Biostatistics, School of Public Health, Imperial CollegeLondon, London and MRC-PHE Centre for Environment andHealth, Imperial College London and Department of PublicHealth and Policy, University of Liverpool, Liverpool, UKVasilis Kontis, Department of Epidemiology and Biostatistics,School of Public Health, Imperial College London andMRC‑PHE Centre for Environment and Health, ImperialCollege London, London, UKSimon Capewell, Department of Public Health and Policy,University of LiverpoolIngrid Wolfe, Department of Primary Care and Public HealthSciences, Kings College London and Evelina London ChildHealth Partnership, Evelina London Children’s Healthcare,Guy’s and St Thomas’ NHS TrustChapter 12  Emerging technologies inhealthcareChapter authorsDominic King, DeepMind and Imperial College LondonAlan Karthikesalingam, DeepMind and ImperialCollege LondonGeraint Rees, DeepMindChapter 13  Data, technology, trust andfairnessChapter authorsMatt Fenech, Future AdvocacyOlly Buston, Future AdvocacyMike Parker, Wellcome Centre for Ethics and Humanities,University of OxfordChapter 14  Embracing uncertainty: futuresthinking in actionRichard Blundell, Department of Economics, UniversityCollege London and ESRC Centre for the MicroeconomicAnalysis of Public Policy, Institute for Fiscal StudiesChapter leadJonathan Grant, The Policy Institute, King’s College LondonMajid Ezzati, Department of Epidemiology and Biostatistics,School of Public Health, Imperial College London andMRC‑PHE Centre for Environment and Health, ImperialCollege London and WHO Collaborating Centre on NCDSurveillance and Epidemiology, Imperial College LondonHarriet Boulding, The Policy Institute, King’s College LondonChapter 10  Machine learning forindividualised medicineChapter leadMihaela van der Schaar, University of Cambridge and TheAlan Turing InstituteChapter authorsMihaela van der Schaar, University of Cambridge and TheAlan Turing InstituteChapter authorsHugo Harper, The Behavioural Insights TeamRoss Pow, Power of NumbersDavid Halpern, The Behavioural Insights TeamJonathan Grant, The Policy Institute, King’s College LondonChapter 15Forecasts for health in 2040Chapter authorsStein Emil Vollset, Institute for Health Metrics and EvaluationChristopher J L Murray, Institute for Health Metrics andEvaluationWilliam Zame, Departments of Economics and Mathematics,University of California, Los AngelesAnnual Report of the Chief Medical Officer, 2018 Health 2040 – Better Health Within Reach Editors and authors page 5

ContentsAnnual Report of the Chief Medical Officer, 2018 Health 2040 – Better Health Within Reach Contents page 7

ContentsA single PDF download of this report is available via www.gov.ukAll of the chapters in this report are also available as discrete downloads. For this reason, every chapter is numberedseparately. For example, Chapter 1, ‘Chief Medical Officer’s summary’ is numbered “Chapter 1 page 1”, “Chapter 1, page 2”etc.Foreword.Editors and authors.Contents.Chapter 1Chief Medical Officer’s summary.Chapter 2Health and economic outcomes.Chapter 3The local health environment .Chapter 4Social health.Chapter 5How will health be experienced in 2040?.Chapter 6Demography.Chapter 7Multimorbidity.Special section – Mental health disorderChapter 8Changing behaviour for a healthier population.Chapter 9Health inequalities – a challenge to current health policy.Chapter 10 Machine learning for individualised medicine.Chapter 11 Emerging technologies – population scale impacts.Chapter 12 Emerging technologies in healthcare.Chapter 13 Data, technology, trust and fairness.Chapter 14 Embracing uncertainty: futures thinking in action.Chapter 15 Forecasts for health in 2040.Acknowledgements.Annual Report of the Chief Medical Officer, 2018 Health 2040 – Better Health Within Reach Contents page 8

Chapter 1Chief Medical Officer’ssummaryChapter lead and authorSally Davies11Chief Medical Officer, EnglandAnnual Report of the Chief Medical Officer, 2018. Health 2040 – Better Health Within Reach Chapter 1 page 1

Chapter 1Chapter title01  The future is here This year for my annual report, I have chosen to focus uponthe health of the public in England in 2040. The NHS isoften a source of national pride, but despite this, a narrativeof health being a cost to society prevails. As the late HansRosling said, “When things are getting better we often don’thear about them. This gives us a systematically too-negativeimpression of the world around us, which is very stressful.”This report offers cause for optimism and I conclude that it isrealistic to aspire to better and more equitable health in thenext 20 years. As the NHS has developed its long-term planfor the coming ten years, this report looks at the strategicopportunities over the coming two decades for the health ofthe nation more broadly.I believe we need to reposition health as one of the primaryassets of our nation, contributing to both the economy andhappiness. We also must measure and track progress in ourdevelopment of health as a nation and our fairness as asociety in delivering improving health outcomes. We need acomposite Health Index developed that recognises this and istracked alongside our nation’s GDP.We need to track progress in improving health and healthoutcomes, to and beyond 2040 with a new composite HealthIndex that reflects the multi-faceted determinants of thepopulation’s health and equity in support of ensuring healthis recognised and treated as one of our nation’s primaryassets. This index should be considered by Governmentalongside GDP and the Measuring National Well-beingprogramme.* We regularly collect most of the datasets thathave the individual measures that could be combined.Recommendation 1I recommend that the Cabinet Office formally explores thedevelopment of a Health Index for England, where that index:nn could be a composite index that is inclusive of healthoutcome measures, modifiable risk factors and the socialdeterminants of health;nn may be disaggregated by composition allowing tracking ofperformance of each component additional to the overallmetric; andnn reflects the multi-faceted determinants of the population’shealth.The investigation should involve the Office for NationalStatistics, which has experience in index development andshould link to their work measuring the United Kingdom’sprogress on delivering the United Nations’ agreed SustainableDevelopment Goals.*My report highlights that we know what we must do toimprove health in 2040, and in many circumstances we arealready doing it. Effective population prevention, such asthe UK government’s Soft Drinks Industry Levy, is alreadyhere. Big data and the computing power to make predictiveanalytics everyone’s business is already here. Artificialintelligence that can diagnose disease earlier and improveprognosis is already here. We need to embed and build uponthese innovations to accelerate and normalise implementationof what works across England.Both prevention and the delivery of healthcare can contributeto a more equitable future. My report discusses the need forcontinued focus on the social determinants of health and asevery cause of death, at every age, is more common in themost deprived, healthcare can directly deliver substantialgains too. For example, my report illustrates that achievingequitable cancer survival in England could avoid 10,000deaths within 5-years of diagnosis (see ‘Socio-economicinequalities in 5-year cancer survival: avoidable prematuredeaths among patients diagnosed in England in 2010” inChapter 9 of this report).To deliver the healthier future that is within our reach, weneed a new paradigm for research. All health-related data,genomics to social determinants, and every patient contactneed to be used to improve the experience, service andprevention for each individual. This dynamic learning andresearching environment will require new approaches toevaluation and introduction of technologies that learn anditerate to deliver the best care to patients without delay.This report has four sections that cover some of the biggestopportunities for health over the next two decades. Thefirst section identifies health as one of England’s primaryassets through analysing the links between health and theeconomy, the local health environment, social health andhow the maintenance and treatment of health could beexperienced in 2040. The next section of this report identifiesthe potential health gains and reduction in health inequalitiesthat could be possible with a ‘prevention first’ approach. Thethird section of this report explores emerging technologiesand their potential impact on health promotion, protectionand treatment. This section concludes by discussing the ethicsof big data, emerging technologies and the fundamental roleof mutual trust between the public and health institutions.Chapter 14 explores current and future uncertainties in healthand identifying the potential of futures thinking methods toinform and ‘future-proof’ health policy.Office for National Statistics. Measuring National Well-being: Quality of life in the UK, 2018. Accessed at: alityoflifeintheuk2018Annual Report of the Chief Medical Officer, 2018. Health 2040 – Better Health Within Reach Chapter 1 page 2

Chief Medical Officer’s summary02  What is health and whatcould it be?03 An uncertain futureAmbition for 2040 That the health of the wholepopulation is considered one of thenation’s primary assets.Ambition for 2040Health is generally used to mean the ‘absence of ill-health’.Society has a focus on the NHS as an ‘illness service’ ratherthan acknowledging the complex interactions in society thatinfluence our health as individuals. Healthcare is often spokenof as a cost to the state and society rather than an investmentthat generates returns for the individual, communities and thenation. The NHS and public health services are not a burdenon our finances – they help to build our future. Moreover, thegood health of our nation is the bedrock of our happinessand prosperity – as I have highlighted in my previousreports,† prevention pays. As the increases in life expectancyexperienced over past decades have begun to plateau, I agreewith the OECD‡ – there are a number of factors at play thatare affecting many countries, which makes it difficult toascribe slowing increases to any specific factor or policy.Health is an asset that we must protect and promote and isaffected by the conditions in which we live and work. Theseconditions can be health-promoting or health-harming, andoften governments, industry, and societies are responsiblefor those conditions, not the individual. We all have someresponsibility for our own health, but we are not individuallyresponsible for the house or neighbourhood we are borninto, the school we attended, nor the health environment welive in.The health system must adapt for each individual and ensureboth their environment and the care that they receive ishelping them achieve ‘good health’. One example of thisis social prescribing, which acknowledges our expandedunderstanding of physical, mental and social health and isan opportunity for the traditional health service to utilise,enhance and amplify existing schemes (see Chapter 3 of thisreport, ‘The Local Health Environment’). One size clearly doesnot fit all, and this requires different types of care accessedthrough different places and different ways.That world-leading approachesto thinking about the future aredeveloped and used to inform healthand social policy impacting on2040, creating the capability in thehealth system to adapt to emergentopportunities and threats to thehealth of the nation.The future is uncertain; unless we consider the future andthe uncertainties that could affect health, how can weplan effectively and know whether our current plans are‘future-proofed’?‘Futures thinking’ is an important part of planning, helpingus to imagine what different futures might bring. My reportencourages consideration of activities and environmentsin the light of whether they are health-promoting orhealth-harming and how much uncertainty they contain asa form of prioritisation for research and policy. In Chapter14, the authors introduce the ‘cone of uncertainty’, wherethey look through the ‘lens of now’ to health in 2040 toconsider different futures for three exemplar areas of interest.The top of the cone represents the best-case or ‘utopian’outcome that we might hope for. In contrast, the bottom ofthe cone represents the worst-case or ‘dystopian’ scenario.Such a process allows the identification of research and policyconsiderations to ensure we set the foundations to plan forand protect a healthier future for all.Futures thinking is vital to planning effective and efficienthealth environments and services going forward. Strategicleaders in healthcare and public health organisations need toembed futures thinking (and specifically scenario planning) inthe development process of long-term plans.Recommendation 2I recommend that the Department of Health and SocialCare, and the health system, invest in capabilities for“futures thinking” in health, for example through PolicyResearch Units.†All of my reports may be accessed online at dical-officer-annual-reports‡OECD/EU (2018), Health at a Glance: Europe 2018: State of Health in the EU Cycle, OECD Publishing, Paris. Available online: https://doi.org/10.1787/health glance eur-2018-enAnnual Report of the Chief Medical Officer, 2018. Health 2040 – Better Health Within Reach Chapter 1 page 3

Chapter 1Figure 14.2Chapter titleThe cone of bablenowSource The Policy Institute, King’s College LondonAs we look to 2040, there are numerous scenarios forthe health of England, some of which are explored in thisreport. The evidence throughout this report suggests weare currently at a fork in the road, with two vastly differentpathways, both plausible for England in 2040. One scenarioconcerns me: if certain current trends were to continueand even worsen, we could live in a society where themost deprived are cut adrift from that society. The gap inlife expectancy and healthy life expectancy could worsensubstantially, aggravated by a digital divide – we must not letthis unfair future be our reality.Alternatively, our society could prioritise health as oneof the nation’s primary assets, making the health of ournation a source of national pride. This society would bringprevention to the public underpinned by a ‘health-promotingenvironment’ coupled with prevention that is personal to theindividual. This is the future within our reach.The final chapter (Chapter 14) in this report specifically looksat the uncertain future for three illustrative areas of varyinguncertainty: anti-microbial resistance (AMR), obesity and theimpact of technology on mental health.In my 2011 Annual Report I identified AMR as a leadingthreat to our future infection prevention, diagnosis andappropriate effective treatment. This chapter states that weare now certain that without significant action, AMR willhave a substantially damaging effect upon future health andthe global economy.The future is less clear for obesity. While a dystopian scenariowhere obesity is the greatest cause of preventable deathsand disability is possible, this is not inevitable; embracing andscaling up the population approaches to obesity and creatinga health-promoting environment would allow England to§The old age dependency ratio is the number of individuals aged 65 and older in the population as alead the world in successfully changing behaviours andtackling obesity.In contrast, the future impact of technology on mental healthis very uncertain. There is concern about the potential harmof technologies, particularly social media on mental healthand it is important to assess the evolving evidence. Further,we must remain cognisant of avoiding a ‘digital divide’, whichcould reshape health inequalities in coming decades. Thisreport however, suggests that the ‘connected world’ has thepotential to transform mental health services and addresssocial isolation.Despite the many uncertainties, we know that the populationwill age to 2040. We expect the most rapid period ofpopulation ageing to occur in the next 20 years, with theold age dependency ratio§ rising from 0.27 now to 0.40 in2040. It is therefore no surprise that estimates suggest a 50%increase in years of life lost due to Alzheimer’s disease andother dementias by 2040. Estimates from the Global Burdenof Disease Study in this report (see Chapter 14) forecastischaemic heart disease will remain the leading cause of yearsof life lost in 2040, but we can expect the current transitionof disease burden from cardiovascular disease to cancers tocontinue. Smoking and overweight/obesity are shared riskfactors for both of these diseases and have the largest rangebetween ‘better’ and ‘worse’ scenarios in these forecasts.This should be cause for optimism; the epidemic of smokingand obesity and sedentary-related diseases is reversible.Health and society as a whole must prepare for the future byrecognising this change in population. Futures thinking is oneway to help challenge our current thinking and prepare.proportion of those aged 16-64.Annual Report of the Chief Medical Officer, 2018. Health 2040 – Better Health Within Reach Chapter 1 page 4

Chief Medical Officer’s summary04 A culture of health for all05  Bringing prevention tothe publicAmbition for 2040Ambition for 2040That healthy life expectancy doesincrease by five years for all, withthe gap in healthy life expectancybetween the most and least deprivedcommunities halved.A healthier working-age population in 2040 is expected totranslate into an economy with higher overall productivecapacity, increased tax revenues and subsequently reducedspending on health-related social security payments,strengthening public finances (see Chapter 2). We know thatinvestment in health, and the causes of ill-health, pays.Inequalities in life expectancy have worsened from 20012016, with the gap in life expectancy between the most andleast deprived deciles increasing from six to eight years inwomen, and from nine to ten years in men (see Chapter 9).Every cause at every age has a higher death rate in the mostdeprived communities despite our NHS. This demonstratesthat both preventing ill-health through addressing thesocial determinants of health and the environment and thetreatment of ill-health have great potential to deliver a moreequitable future.The majority of people living in poverty now are in workinghouseholds (see Chapter 4). This report not only highlightsthe links between poor health, low educational attainmentand poor job prospects but also the stark regional disparitiesand clustering of these links (e.g. the North East of Englandconsistently has high claimant rates). Rebalancing the costof living with income (earned or otherwise) presents as lowhanging fruit to improve the health of the nation. Indeed,I am concerned that social determinants of health such ashousing conditions could worsen for the most vulnerable,which would risk a re-emergence of communicable diseasesthat were eradicated from England decades ago.Within our reach is an alternative for 2040. A person’s healthis an important component of ‘human capital’** – indeed itis pivotal to other components including the developmentof educational attainment and productivity. The NHS is builtupon a social contract: solidarity where we prioritise collectivehealth security and collective wellbeing. Applying thisapproach of collective wellbeing to the causes of ill-healthcould have a ma

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