Chapter 1
Britain is an increasingly sick nation. The multiple decades of extending life expectancy are over. The health gains from modern medicine have plateaued. We are living longer but not necessarily longer and healthier. By the time a person is 75, they are 60 per cent more likely to possess two or more significant conditions. This figure increases to 75 per cent for those between the ages of 85 and 89 years old.[_] This presents the health system with a serious demographic challenge. The impact of multiple chronic diseases and comorbidities has brought it to its knees. The NHS operates using a model developed in the last century, focused predominantly on treating late-stage symptomatic diseases with almost no cures and putting very little effort into preventing disease or managing disease in its asymptomatic phase. We are, as a system, shooting at the wrong target.
We know now due to advances in biomedical and clinical sciences that 80 per cent of the natural history of major chronic disease is in the presymptomatic phase. Early intervention can dramatically halt disease progression before irreversible damage is done. We all live most of our lives in a miasma of risk factors – raised cholesterol, hypertension, increased body mass – but only in later life do the diseases propagated by these factors emerge as symptomatic disorders: heart attacks, strokes, diabetes, dementia. The current system has not established the necessary early detection and demand management to prevent end-stage disease.
We are treating disease too late and, as a result of pent-up demand, our NHS cannot cope. We have a sustainability crisis in health and a drag on the economy with large numbers of individuals out of the workforce because of chronic disease. Economic growth and productivity are both being severely damaged by chronic ill health, not to mention the levels of individual suffering created by this problem.
The good news is we now understand the problem far better than ever before and innovation in diagnostics and therapeutics, along with new public-health policies, can change this worrying trajectory. Simple health screening will identify individual risk factors such as low-density lipoprotein (LDL) cholesterol, blood pressure and BMI for cardiometabolic disease. Circulating tumour DNA (ctDNA) blood tests will allow us to identify cancer early. Genomics and artificial intelligence (AI) will help us understand the lifetime risks carried by individuals in order to create personalised prevention plans.
Proactive early detection will require early intervention. Alongside existing solutions, we have a new generation of long-acting therapies that can be used to manage risk factors such as cholesterol and blood pressure based on annual injections, effectively vaccines for heart disease and stroke. Inclisiran alone could prevent 55,000 heart attacks and strokes,[_] while treating someone for five years after they have a stroke can cost the NHS as much as £45,000.[_] And, for the first time, we have a new set of therapeutics that will help us tackle the biggest of all risk factors, obesity, which alone costs the country nearly 4 per cent of its GDP in illness and losses in productivity.[_]
Reducing the burden of chronic disease will have profound impacts on society and will importantly save the NHS, allowing it to focus on the treatment of acute and rare disease. People are living longer but spending more time in ill health, often with more than one condition – demand on the NHS has never been so high. As of September 2023, there were a record 7.77 million people waiting for NHS treatment.[_] This is why it is also important to proactively manage adult infections that can be mitigated using vaccines. We have effective vaccines and interventions for many diseases and, if adequately deployed, these could reduce instances of disease and prevent hospital admissions. For example, there were 40,500 fewer GP consultations for shingles-related disease and 1,840 fewer hospitalisations in the first five years of the national shingles programme.[_]
There is even emerging evidence that vaccines for flu have positive cardiovascular outcomes[_] and vaccines for shingles can potentially reduce the risk of dementia up to 20 per cent.[_]
Simply put, we have the tools but have not yet put them to proper use.
As elegantly described in this paper, there are good ideas about how to make the most of these tools. Solutions lie in a model that focuses on early detection and early therapy as well as anticipating disease with targeted prevention. Such a strategy would create a genuine “health system” rather than a “sickness system”, which we operate now.
The principles laid out in the coming pages are critical. First, the new system for prevention must work outside but alongside the NHS, which must prioritise fixing other challenges in treatment waiting lists and acute care. Second, this needs to be convenient and accessible, digitised and community based. It requires few doctors and little physical infrastructure. As we showed in the pandemic, the capability to deploy injectables and vaccines at scale in the community can be done efficiently and at speed with digital systems and trained health associates. Third, effective communication with the public about how to proactively protect their health is essential. This must be the future of health care in Britain, and this paper creates an initial example for a roadmap for how it could happen.
Sir John Bell
Regius Professor of Medicine, University of Oxford
Chapter 2
We now have in our grasp the technology and tools necessary to make smarter, earlier and faster interventions in health so we can move from treating disease to preventing disease. Spurred by the Covid-19 pandemic, there are more vaccines in the pipeline than ever before and now is the time to prepare the UK’s health system to absorb a new age of innovations that are proved to be safe and effective. The next government must as a matter of priority institute a new programme for prevention that introduces the innovations available to us now and the community-level infrastructure necessary to deliver proactive care. By protecting Britain’s health we will protect the National Health Service, save money and save lives.
The nation’s ill health is hurting its economy. An estimated 2.6 million people[_] are now out of work due to sickness and a record 104.9 million working days are lost to long-term health conditions every year. Against a backdrop of continually rising health-care costs – we’re now spending 40 per cent of the NHS budget treating preventable diseases – it’s clear that we must shift health care towards prevention, both to save lives and to save money.
We propose launching Protect Britain – a new, nationwide preventative-health programme that would sit alongside the NHS, reporting to the Secretary of State for Health. The programme would bring preventative vaccines and therapeutics to everyone in Britain who is at heightened risk of dying or having their quality of life or employability threatened by a preventable or chronic disease. Preventable conditions are costing the NHS and wider society hundreds of billions of pounds. Even if this programme reduced the prevalence of preventable conditions by a third, it would massively reduce treatment costs, save lives and make Britain more productive.
This needs to be delivered in the most effective way possible, and not solely through traditional primary-care routes, but rather by building on the infrastructure that successfully delivered Covid-19 vaccines such as mobile clinics and data-led outreach, adding new ways to protect and reach the widest set of people. It must have innovation at its core. The technology now available means that we can shift from population health to personalised health care. There have never been more vaccines in development, AI-enabled technology is already being trialled in the NHS, data from the NHS Genomic Medicine Service can inform better preventative treatment, wearables can detect illness through key metrics and new tools such as liquid-biopsy technology can screen for disease. Crucially, by creating a dedicated platform, Britain can move at the speed of this innovation and rapidly bring new treatments online to those who need them. We must avoid overburdening an NHS that has record waiting lists and that can become the best in the world at treatment. This is the combination Britain deserves: world-class disease treatment and world-class disease prevention.
Over time, Protect Britain would include health screening and preventative services across a range of diseases and ensure Britain is at the forefront of procurement by adopting a model akin to that of the Vaccine Taskforce set up during the Covid-19 pandemic. Advisory services and social prescribing, including incentivising exercise and healthier diets, will enable citizens to change their lifestyle and thereby reduce their long-term disease risks. This is critical if we’re to reverse a trend in obesity that already costs society £98 billion a year.[_] This is why a programme like Protect Britain should be seen as an investment in both the nation’s health and its economy. Short-term costs will be met by the taxpayer, but these will be outweighed by savings over time as treatment costs are avoided and healthier people become economically active for longer. For every ten-percentage-point increase up to 60 per cent coverage in workers’ vaccination rates for influenza alone there is a projected gain of £380 million to the UK economy. Across multiple diseases and conditions, this figure will be huge.[_]
Protect Britain should start small but be given the power to add more preventative services to its portfolio as its budget grows and as they become available. It should be sufficiently resourced to be able to move at speed to ensure health screening – an aspect of prevention the NHS is not sufficiently delivering – is applied to the whole population across all age groups, and then to capitalise on the most innovative and effective preventative therapeutics and vaccines.
Protect Britain would be data-driven, with eligibility determined by digitally connecting and reading a patient’s record. The collective, nationwide insight on this scale would provide real-time data on the effectiveness of preventative interventions and give Britain a competitive advantage in life sciences. It would serve as the ultimate level of demand management for the NHS, preventing or delaying the onset of severe diseases, freeing hospital beds and making the NHS sustainable.
This programme could potentially save the NHS billions in treatment costs – for example, reducing obesity by 10 per cent could save the NHS £2 billion a year. TBI will be publishing detailed modelling in a paper next year that sets out cost savings in more detail.
Examples of conditions that could be included in this programme are listed in Figure 1. Numbers from various sources have been included and in some cases represent data from different years. These conditions will not be the main source of cost savings from the programme as many of these interventions are already being rolled out by the NHS in some form. It is the case, however, that these interventions aren’t offered anywhere near routinely enough or, if they are, that they take too long to reach patients. Plus, there needs to be a dedicated function within the health service that coordinates preventative interventions – and a programme like Protect Britain would fill that role.
Routine, community-based intervention to prevent conditions and diseases could make people healthier and more productive
* Protect Britain would save money, save lives and enable more people to participate in the economy, but it will not result in these costs being completely removed. TBI will publish detailed modelling on the cost savings of such a programme in 2024.
** Between week 40 of 2021 and week 14 of 2022
*** The estimated costs are the consequence, in part, of an estimated 467,230 general-practice (GP) visits and 33,937 hospitalisations per year in the UK for children aged under five with RSV, according to the same study.
Chapter 3
A preventative-health programme like Protect Britain would have a mandate to secure the supply and promote the uptake of available, proven preventative vaccines and therapeutics, and to drive innovation for the next generation of life-saving interventions.
Many preventative interventions are available now, but without a dedicated programme they risk being lost in a health-care system that is built around reactive treatment rather than proactive prevention. As new, innovative products are coming online, they tend to be layered into existing routes for treatment. Instead, these new vaccines, therapeutics, diagnostic tools and treatments should transform the way we monitor, treat and prevent disease – not just act as an add-on.
Chapter 4
The preventative programme we propose should focus on transforming health care through three areas:
Prevention: Reducing the risk of contracting certain diseases and conditions and mitigating their impact.
Screening: Identifying conditions and diseases early and understanding personal risk.
Innovation: Adopting and making available new, proven innovations at speed and directing research towards priority conditions and diseases.
Prevention
The NHS treats diseases that are avoidable, accounting for 40 per cent of NHS costs.[_] The burden of obesity on the NHS, a risk factor for developing diabetes, is estimated to be around £19 billion per year and costs wider society £98 billion per year[_] while it is estimated that diabetes alone costs the health service £10 billion a year – around 5.5 per cent of its budget.[_]
A programme like Protect Britain would be charged with proactively identifying patients who are at risk of or suffering from preventable diseases and conditions. This would draw on a data-driven approach that utilises individual patient records and, deploying tactics from Covid-19, engages individuals directly to support them in making use of preventative measures. This proactivity and outreach would mark a shift away from a primarily reactive health-care service.
Preventative measures would not be limited to vaccines. The programme would recommend and provide therapeutics that can reduce the risk or impact of chronic diseases and conditions like obesity and diabetes. This could include statins. Protect Britain would likely implement National Institute for Health and Care Excellence recommendations that eligibility for statins (which are already widely rolled out in the UK and saving lives) is widened dramatically, empowering 15 million more people to take them to prevent heart attacks and strokes.[_]
Reducing obesity has positive knock-on impacts for reducing risk of other diseases. For example, it is a major contributing factor to musculoskeletal pain. Reversing the rise in obesity could reduce the number of people in the UK living with a musculoskeletal condition – estimated to be around 20 million – and in time, the 1.08 million hospital admissions and one in seven general practitioner (GP) consultations associated with it. Prescriptions for musculoskeletal conditions in 2021–2022 amounted to £151 million.[_]
Reducing obesity can also reduce an individual’s risk of developing other chronic conditions like type-2 diabetes. Having obesity or overweight accounts for about 80 to 85 per cent of an individual’s risk of developing type-2 diabetes.[_]
The same goes for respiratory-syncytial-virus (RSV) infections, which, in older adults, account for 8,000 deaths, 14,000 hospitalisations and 175,000 GP appointments every year. These figures can be higher than those attributed to influenza during a typical winter season. In July 2023, the Medicines and Healthcare products Regulatory Agency approved Arexvy, the UK’s first vaccine against RSV for use in older adults,[_] but there are no plans yet to roll it out to them. Doing so could be a priority for a programme like Protect Britain, preventing thousands of infections. Protect Britain could identify at-risk individuals and target that group as priority for Arexvy if the supply is limited at first.
Respiratory-virus vaccines will reduce the demand on hospital beds created every winter by respiratory viruses. Flu alone is associated with an approximate average excess of 27,000 emergency inpatient admissions from A&E per month, and an average excess of 16,000 patients per month waiting more than four hours to be admitted to hospital from the A&E.[_]
Boosting access to flu jabs would reduce pressures, helping to cut waiting lists and prevent people from getting seriously ill in the first place.
A broader approach to prevention and improved physical health delivered via Protect Britain could also improve the nation’s mental health, with the link between developing physical and mental health problems clearly established.[_] The most recent Office for National Statistics (ONS) data on ill health and the workforce found that depression, bad nerves or anxiety were the most commonly reported health conditions for those who are out of work because of long-term sickness, with 53 per cent (more than 1.35 million people) reporting it as a health condition in 2023.[_]
Screening
We need to screen for conditions and diseases throughout adult life and treat them early. Not only does early diagnosis often increase the likelihood of successful treatment and survival, it’s also a massive opportunity for public-health gain at very low cost.
New diagnostic tests and screening opportunities are being developed and trialled all the time. For example, the NHS-Galleri trial is looking into the use of an early-detection blood test that can potentially identify more than 50 cancer types while an individual is still asymptomatic. Although the test is not yet available outside clinical-trial settings in the UK, early results in the United States look promising.[_] If approved, the Galleri test could be used to proactively identify cancer at its earliest possible stages.[_]
A new preventative platform in Britain would evolve to include genomic sequencing. The costs of sequencing a human genome have fallen from $100 million to under $1,000 since 2001 and this is likely to fall further.[_] This would give individuals an understanding of their risk and enable them to access treatments and advice that could lower or even remove risk entirely.
Our Future Health
Our Future Health is the largest health-research programme that has ever been run in the UK. Involving the public, charity and private sectors in partnership with the NHS, its ambition is to develop new methods of preventing, detecting and treating disease.
Our Future Health provides volunteers with a simple health check and is aiming to recruit 5 million participants.
With just one-fifth of its target recruitment number signed up, the study has already identified people that had undiagnosed high cholesterol and uncontrolled blood pressure who would have otherwise gone undiagnosed by the health system.
Read more at: https://ourfuturehealth.org.uk/
Innovation
By acting now and launching a preventative platform, the country will be at the forefront of artificial-intelligence (AI) advances and be able to bring them into the system faster, accelerating tech-adoption processes. Given the speed at which technology is developing, it’s important we have a system that can quickly absorb new innovations and eventually coordinate and direct funding to research that meets the current and future needs of Britain’s population. Patient safety and diligent testing and research must remain paramount before any new treatment is rolled out.
Now is the time for a platform that prioritises adopting new preventative technologies. Spurred by advances during the pandemic, we are in an age of vaccine innovation. The successful rollout of mRNA technology and the exponential power of AI give rise to many more combinations of vaccines that, critically, can now be developed, tested and delivered to the population at speed. Some examples of such innovations include:
A new era of vaccines: Spurred by the Covid-19 pandemic, more vaccines are in the pipeline than ever before, and the government should prepare the UK’s health system to absorb those that are proved to be safe and effective. The number of mRNA cancer vaccines in development has more than doubled since 2017, with 21 in development globally in 2022.[_]
Transformative AI: New AI-enabled technology being trialled in the NHS has led to quicker treatment and improved outcomes for stroke patients.[_]
The power of “omics”: Data from the NHS Genomic Medicine Service could be linked to Protect Britain to improve prevention and treatment, bringing greater precision to individual risk and treatment advice. Anyone identified as having risk factors for certain preventable diseases could be included in the rollout of the relevant preventative vaccine or therapeutic sooner.[_]
New treatments: The ability to combine advances in the biomedical field with the ability of AI to speed up the drug-discovery process means that novel and expensive treatments for diseases like cancer can in time become mainstream. For example, CAR T-cell therapy for cancer is considered a complex and specialist treatment, but with time and technology it can become mainstream. A programme like Protect Britain can help facilitate these transitions.
Wearables and personalised health care: The technology now available means that we can shift from population health to personalised health care. As we’ve written previously, in time, at-home diagnostics, wearables and personal devices can give patients greater control over their health.
Earlier detection: There are also innovations being made when it comes to our ability to screen for diseases. Liquid-biopsy technology has the potential to improve treatment for people who have been diagnosed with cancer, but researchers are also now exploring the potential to use circulating tumour DNA (ctDNA) for early detection and screening.[_]
Those are just a handful of examples of how technology and AI are going to revolutionise health care.
New innovations are coming online every year. Protect Britain would better enable the country to adopt and roll out new, effective vaccines and therapeutics as they become available rather than rely on an overburdened NHS to roll out individual campaigns.
Apollo ProHealth
Apollo Hospitals Group in India has rolled out Apollo ProHealth Program, a proactive and preventative health-management programme. It is powered by personalised health risk assessments, which are enabled by AI.
A personal health risk assessment is available digitally to every participant. Based on their results, they can visit the nearest Apollo facility to conduct the customised recommended set tests.
The ProHealth Program allows individuals to be aware of their risks of certain diseases, receive diagnoses earlier and benefit from personalised advice on follow-ups with relevant diagnostic tests and health packages to monitor identified conditions or risk factors.
Towards a Healthier Workforce
The cohort of working-age adults who are out of the labour market is growing. According to the ONS, this is increasingly due to long-term sickness.
The rise in long-term illness began before the pandemic. However, the pandemic has exacerbated the issue. Since 2020, the number of people out of work due to illness has risen by about 360,000 people.[_] Around 30 per cent of the 8.8 million economically inactive people in the UK are off work due to long-term sickness – the highest share in at least 30 years.[_]
According to one study, seasonal flu can lead to £644 million in losses to the UK’s economy (0.04 per cent of GDP). Driving uptake of the effective vaccine already available for this condition would reduce this figure.[_]
The benefits of a programme like Protect Britain would be broader than straightforward NHS cost savings. Some of those benefits include:
Saving on health-care costs by offsetting future treatment costs
Relieving pressure on the NHS, particularly during the challenging winter months
Boosting productivity by reducing absence rates
Increasing worker participation by extending years of healthy life
Reducing the cost of future pandemics by investing in infrastructure that is “always on” and can be repurposed against a novel virus
Chapter 5
Protect Britain would adopt a similar delivery model to the vaccination infrastructure built during the Covid-19 pandemic, with multiple settings able to administer and record vaccines and a digital health record that allows citizens to keep track of their inoculations. This creation of a national digital capability to contact people and enable them to come and be screened and treated with risk-factor-lowering therapies will be critical. At scale, these data would provide unparalleled insight into the effectiveness of vaccines.
Infrastructure for a Preventative-Health Programme
The NHS vaccine strategy published in December 2023 recognised the importance of rolling out vaccines locally, expanding beyond GPs and pharmacies to include shopping and community centres. Our Protect Britain proposal draws on this approach.
Setting: Prioritise ease and uptake by delivering preventative vaccines and therapeutics in the settings where people live and work. This means not being limited to primary-care settings but instead including large employers, colleges, job centres, local pharmacies, and popup and mobile centres.
Supply: Agree novel commercial arrangements to bring down the cost of preventative vaccines and therapeutics.
Staffing: Create a new workforce to deliver vaccines alongside administering health care daily. This could include accelerating the deployment of trainee medical staff to administer jabs and formalising the volunteer vaccine workforce that delivered during the pandemic.
Systemisation: Use patient records to ensure people are aware of what they’re eligible for and enable them to book preventative vaccines and therapeutics online.
Support: Provide facts on vaccines and therapeutics available through a dedicated information resource. The NHS app should become a key interface, linked to a patient’s record, that provides personalised interactions and builds a relationship with citizens.
To maximise uptake and combat disinformation, a preventative programme like Protect Britain should be accompanied by a public campaign designed to make people aware of the service and their eligibility and use a revamped NHS app to create a single entry point into an individual’s health. The ultimate objective should be a cultural shift: creating a new understanding of the role preventative vaccines and therapeutics can play in our health and working hard to reach target populations. The campaign would include an educational component aimed at reducing misinformation around vaccines and should draw on data to identify, target and build a relationship with the eligible population.
Chapter 6
Delivering a preventative-health programme will require political leadership at the highest level. It should become a national health priority. We propose the following:
Launch Protect Britain, a preventative vaccine and therapeutics programme reporting into the Secretary of State for Health that is delivered throughout the year and aimed at preventing diseases, saving lives, reducing pressure on the NHS and enabling people to participate in the job market.
Empower such a programme to shift health care in Britain from treatment to prevention through the “PSI model”: prevention, screening and innovation. This will be delivered by procuring, prioritising, targeting and rolling out available adult vaccinations, therapeutics and other preventative-health measures, and creating a regulatory framework that allows new vaccines and therapeutics for preventable diseases to be developed and tested at speed.
Enable the use of risk-reducing preventable technologies such as statins and drugs for weight loss to begin managing the risk of common chronic disorders, alongside targeted vaccines and therapeutics such as those reducing a patient’s risk of shingles, RSV and flu.
Utilise infrastructure and digital tools developed during the Covid-19 pandemic to build capacity alongside the NHS, identify and reach eligible citizens, track progress, and administer vaccines and therapeutics.
Start small but build this preventative programme into a comprehensive preventative service over time. This would include exploring a new fiscal framework that has a statutory duty to assess the holistic costs and benefits of new preventative-health interventions that could be administered through a programme like Protect Britain, for example through a National Health Account or an Office for Protective Health Spending.
Lead image: Getty