Health and care have been inexorably moving towards a new paradigm of precision health over the last 20 years—the result of changes in the provision of services, increasing challenges around affordability, as well as societal changes to demography, morbidity and the nature of the interactions between physicians and patients.
In the 1990s, the atmosphere was very different to the one which prevails today. The world of evidence-based care was just about reaching the mainstream in its acceptance and everywhere there were examples of attempts at implementation and deployment of these new pathways within health systems.
Change was also difficult then, and change management was—as it is now—the major challenge. There were fierce and impassionate arguments by some in the clinical fraternity about the potentially erosive nature of the clinical governance which was how evidence-based care was being introduced. Since then, our understanding of evidence-based care and the need to deliver optimal rather than opinionated care has matured, but perhaps not quite as much as we would like to see.
Other things have changed. The patient has become more assertive—less likely to blindly follow pathways of care that are not necessarily relevant to them or their aspirations. Patients have indeed taken on some attributes more akin to a consumer, where, imbued with a newly found primacy we are all used to exercising in the world of commerce, we have really expected services to be delivered to us in a way which is timely, efficient, and personalised to our needs and aspirations.
These new personalised interactions offer opportunities for us as clinicians to demand more of people in that the effect of this level of personalisation is a greater requirement for the person to be more active in pursuit of reducing risks that have an adverse effect upon the development of non-communicable diseases.
These approaches altogether have fundamentally changed the nature of the relationship between patient and physician, as they make for a far more engaged relationship which takes place over longer periods of time.
Thus, in the management of conditions like cardiovascular disease, the cancers and other non-communicable diseases, interactions tend to occur over a life course as the reference frame, rather than the late middle age and older age groups when people typically start to exhibit symptoms of non-communicable diseases, given we now understand far more how to prevent ill health and delay disease and symptoms.
This approach thus translates into interactions with the person when they are well, before they are symptomatic. Given the nature of the personalisation in terms of care pathways and treatments people, we are now habituated to terminology like precision medicine in the treatment of disease. Similarly, our approach in wellness is as personalised, hence the term precision health.
Health systems are now making attempts to directly engage with people over a life course, usually using digital modalities as the medium of communication. They are also using techniques like “nudge” and supplementing this with elements of gamification, to ensure every opportunity is taken to maintain engagement and sustain behavioural change.
COVID-19 has given a new impetus to this process. Like all major adverse events which affect complex systems, there have been some occasional unexpected positive ones, like the fact that digital modalities have now become far more accepted. As Vladimir Ilyich Lenin, not ordinarily someone I would look to for inspiration, said, “There are decades where nothing happens; and there are weeks where decades happen.” This is precisely what has happened with digital transformation over the past few months, certainly with regard to the management of non-communicable diseases, where the speed of uptake and acceptance by clinicians has surprised us all.
There is much we still all need to do. The whole edifice of this precision health approach is based on the appropriate layering of data from various sources to provide that granularity and insight we require to craft pathways of care which resonate with the individual. To do this, we need access to data and we need to have a trusting relationship with our patients.
To date, it could be argued that we have not done enough to assist our populations to understand the benefit of technology and the fact that the use of data to personalise their health and care is in their interest. The conversations about privacy, secondary use of data, and the potential to overlay data which will allow us to deliver a far more personalised and appropriate offering to people have not been well articulated. The potential adverse effects associated with the inappropriate use of data predominate when one looks to the column inches in newspapers or in the media.
We need to reinvigorate conversations around precision health where they have started and start them where they have not yet been initiated. If there is something which history teaches us, it is that in places which have had open vigorous and prolonged debate around the most appropriate secondary use of data, the chances of a successful conclusion increase.
Success is a place where the balance between the rights of the citizen to privacy is given the weighting it deserves, and this is balanced by the potential advantages of an individual of allowing their data to be used in a predetermined and mutually agreed manner.
These discussions are not likely to be simple as the journey to get to a situation of trust never is. As we know, trust takes years to build, seconds to break and forever to repair. We know delivery of health and care to people is not an easy task so none of this should come as a surprise.
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