future scenarios in the uk healthcare
Technological developments
The main areas of technological development likely to affect healthcare towards 2015 have been categorised as33:
- advances in molecular genetics, with the progress of the Human Genome Project identifying genes causing monogenic diseases such as cystic fibrosis and genetic susceptibility to polygenetic disorders such as coronary artery disease
- developments in biotechnology which will enable advances in genetics to be exploited, vastly increasing the range of treatments and cures available
- development of bioengineering to produce artificial body parts and organs, predicted to replace transplantation within the next three decades
- further developments in minimal access surgery, forecast to account for half of all surgical interventions within ten to 15 years, and image guided surgery, exploiting developments in magnetic resonance imaging
- use of robotics in surgery, increasing accuracy and consistency, and in rehabilitation
- further developments in transplantation, with more success in controlling rejection and the impact of bioengineering leading to its use as a treatment for a wider range of conditions, including for example Parkinson’s disease
- IT and telecommunications, including decision support systems, developments in medical record keeping and transfer, aids to rehabilitation and enablement, and its impact on public access to information.
The World Health Organization34 also predicts new treatments for various diseases:
- new drug therapies for treatment of schizophrenia available on line within the next 10-15 years without any of the negative side-effects of the current treatment regimes
- development of prevention of cataracts within the next ten years through use of antioxidants
- development of one or more vaccines for HIV infection by the end of the decade, utilization of different points in the life cycle of the HIV virus for intervention possibilities
- dvelopment of childhood ‘vaccination’ for type 1 diabetes.
“in utilizing new technologies, the challenge remains of ensuring that these are not adopted in a fashion that serves to reinforce, or even widen, the existing inequities in health, thus maintaining or aggravating societal strains…the need to guard against dominance by expensive high technology therapies which benefit only relatively few people is as urgent as ever.”
Technological advances may be less useful because of problems with implementation. For example, in the UK the development of telemedicine has been restricted by medicolegal and ethical concerns about security, confidentiality and integrity of information35. Issues in implementing genetic advances have already been identified:
Although genetic services in the USA are marketed directly to patients by the private sector, in the UK they are likely to be integrated within the mainstream of primary care, with implications for training, workload and resourcing36;
GPs may be unwilling to raise the issue of genetic risk with patients in the absence of effective screening technologies and therapies to reduce risk or prevent disease, and patients may be unwilling to make lifestyle changes in the context of genetic determinism37;
Genetic screening and selection within reproductive technology potentially allows parents to specify their child’s characteristics, raising difficult ethical issues about the value of life38.
The development and implementation of new technologies will also be affected by the extent to which they are seen to be safe and ethically acceptable. For example, the cloning of Dolly the sheep in 1997 led to widespread rejection of the principle of reproductive cloning of humans39, whilst fears of disease transmission have held back research into xenotransplantation40.
Financial factors will also be influential; for example, developments in genetics and biotechnology are encouraged by the prospect of market returns, such as the cost of implementation and the prospect of developing marketable products. Whether new technological developments represent appropriate uses of a limited supply of public funding will be an increasingly important issue. For example, Dargie suggests41:
The public policy questions about funding and developing equipment to help premature babies raises both ethical and funding issues. The difficult question in public policy terms is not only whether money should be spent developing this type of care, but also whether we should divert money from other sources in order to provide it.
Technological development has often been cited as the main reason for the recent increase in healthcare costs throughout the developed world. However, some commentators disagree:
“The assumption that new technology must lead to substantial increases in cost that probably cannot be met is neither subject to sufficient questioning nor supported by empirical evidence. An analysis of new medical technology introduced during the 1970s would not support the assumption that new technologies increase costs, and it is unclear whether new technology was the cause or an effect of increased spending during that period42".
However it is also argued that, whilst the costs associated with new technologies are case specific and some may contribute to cost reduction, their adoption and use is generally resource intensive, requiring capital investment and additional specialist skills43. There will therefore be a need for assessment and evaluation of the cost-effectiveness of the new technology and whether it substantially improves outcomes, and rationing, and possibly a tension between the availability of treatments on the market and the constraints on public sector funding.
33 G Robert. Policy futures for UK health: 1999 Technical Series No 4 Science and technology. London: Nuffield Trust, 1999.
34 World Health Organization. Health Futures: in support of health for all. Geneva: WHO, 1993.
35 B Stanberry. Medicolegal aspects of telemedicine. In R Wootton & J Craig (eds.) Introduction to telemedicine. London: Royal Society of Medicine Press Ltd, 1999.
36 A L Kinmonth, J Reinhard, M Bobrow, S Pauker. The new genetics: Implications for clinical services in Britain and the United States. British Medical Journal 1998; 316: 767-770.
37 S Kumar & M Gantley. Tensions between policy makers and general practitioners in implementing new genetics: grounded theory interview study. British Medical Journal 1999; 319: 1410-1413.
38 M Evans. Policy futures for UK health: No 9 Ethics. London: Nuffield Trust, 1999.
39 British Medical Association. Human cloning: a discussion paper for the World Medical Association, BMA, 1999.
40 Health fears halt pig organ funding. BBC news online: health, 14.8.2000.
41 C Dargie. Policy futures for UK health: 1999 Technical Series No 3 Demography. London: Nuffield Trust, 1999.
42 S Frankel, S Ebrahim, G Davey Smith. The limits to demand for health care. British Medical Journal 2000; 321: 40-45.
43 P Kanavos. Policy futures for UK health: 1999 Technical Series No 5 Economy and finance. London: Nuffield Trust, 1999.