Building Healthy Places with Sir Malcolm Grant of the National Health Service of England
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- Thank you very much Greg
for that introduction.
And I'm absolutely
delighted to be here.
I was just reflecting
my very first ULI meeting
was in Los Angeles in 1985.
So I'm a 30-year veteran.
I just say that
for safety and security
in case anything goes wrong
during the course
of my comments this morning.
But it's an enormous privilege
to be able to speak
this morning in front of a group
of true global leaders
in an industry that is so important
to the topic
that I'm about to address.
I had the privilege of sitting through
part of the session this morning
and listening not only
to the re-colonization
of the United States proposal coming from Sir Stuart Lipton.
But also to the huge emphasis
in your voting
around leadership,
and that will be one of
the key themes for this morning.
This is going to be less of a keynote
and more of a romp.
I've got more slides than
you could ever possibly enjoy.
But I think there's a possibility also
that we might have them
printed out and distributed
subsequently for reabsorption
on the way home.
I've been asked to talk
about healthy places,
and I've designed
my discussion this morning
around these six major themes.
I'm going to start by talking about
the global burden of disease.
Over the past decade or two,
we have seen an extraordinary shift
in the impact of disease on mankind.
And about 22 nations
still in Africa,
the emphasis is
on infectious disease.
Some 70% of years of life
that are lost to disease
through premature death
are still caused by infectious disease
and related conditions.
Actually, in the rest of the world,
in certainly the 47 mainly
high-income countries
infectious disease is largely
a thing of the past.
Some 90% now of years lost
of life to disease
is a consequence
of non-communicable disease.
And the trend is very clear.
We have a hundred
other countries transitioning
from the plague of infection
to the plague of human behavior
that is of non-communicable disease.
I've produced here a slide which
comes from a very interesting study
which was done by
McKinsey's Global Institute
just published towards
the end of last year.
The incidence of
non-communicable disease—
by the way, this is
a free eyesight test
for the entire room.
And if you think this one's bad,
I've got even better ones
coming along.
So don't worry too much
because the big blobs
on the right-hand side
give you a sense of
what the trend is.
So the trend is global social burdens
in the area of
non-communicable disease
start with smoking
and with armed violence,
war, and terrorism.
By the way, I think
what MGI did on this
was to combine
the US defense budget
with everything else
and put it under heading two
which is one of the reasons
why it looks so dramatic.
But of course there are
parts of this world
where the major cause of death
is armed violence and terrorism.
Just look across the spirit
of the Middle East.
We are in an era where
it's numbers one, three,
and downwards
that are our major causes
not just of premature death,
but of amputation of low limbs,
of blindness,
cirrhosis of the liver,
and the other maladies
that are a consequence of us,
of the way that
we behave as individuals,
not of infection
coming across to us
from elsewhere.
But look at the list.
Smoking, obesity—
I'll come back to those two—
alcoholism, illiteracy,
climate change,
outdoor air pollution,
drug use, and goes on.
Road accidents, by the way,
are falling in many countries.
But their place is being taken
by other causes of ill health.
So let me then start to look
at the cultural
and temporal differences
and the way in which
we run healthcare systems.
So we can look at health
as a phenomenon.
I'm going to turn now
to look at healthcare
as a system and what its impact is
on the malady
that we're talking about.
Let's start with the way in which
different countries
prioritize their spending
on healthcare.
This is another fantastic eye test.
But I wonder if anybody could guess
who is the large expenditure nation
on the far left-hand side.
- the U.S.?.
- Yes! It is.
But look what is so interesting.
Look at the way the bar is divided.
The dark blue part is
the public expenditure on health.
And if you look at that
public expenditure on health
as a proportion of GDP,
the U.S. is way up there,
and its tax payer funded
proportion of healthcare.
The difference between this
and many of the other nations
is in the private copayment
element of healthcare.
And I shall show in a moment,
payment and the expense
that's put into healthcare
does not necessarily correlate
with the outcomes
that you would expect
from healthcare.
This is a slide of which—
well, I always have
to show this because look.
Look, the NHS does so well,
if we look at the overall
ranking of healthcare system—
by the way, this is entirely neutral.
It's generated by the Commonwealth Fund out of New York,
entirely objective
and simple and clear.
Data-driven analysts rank the UK—
you'll the last two columns.
The UK is ranked number one
for effective care,
for safe care,
for all the other
patient-centered care,
and the US on the right hand—
far right hand column—isn't.
But—[audience laughing]
But look at the bottom
right-hand corner.
So there's the UK again.
1, 1, 1, 1, 1, 1, 1.
Bottom right-hand corner,
healthy lives.
Where are we suddenly?
We're number 10 on that list.
And the US is number 11.
So we're doing some things
that are perfect,
some things
that are absolutely right.
And there are some things
which are the consequences
which are completely wrong.
Healthy lives.
Sorry?
France on healthy lives.
Yes.
So we are in the right place.
[audience laughing]
Just need to stay a little longer
for the influence to be felt.
So—
Right. Well, that was the easy slide.
[audience laughing]
[audience laughing]
This one is so difficult to read
that I can just make it up
and you'll be obliged
to observe it.
But what it does is a lot of things.
And in an attempt
to make it more intelligible—
but by the way,
this is a brand new report
out of Commonwealth Fund
just last month.
And what it does whenever you
get a chance to read it,
it gives us an understanding
of two or three key indicators.
Number one is what is the proportion
in this society aged over 65?
Another one is what is the proportion
of the population
suffering from obesity?
And on the obesity scale,
as we'll see,
we range from Japan at under 4%
to the US at over 33%.
The UK, about 25%—
roughly the fattest nation in Europe
and other nations across the piece.
It also gives you details
of the incidence of smoking
in the adult population
where the US, by the way,
is way down,
now down to about 14-15% percent
of adult population
as opposed to the UK
which is about 19.8%;
Germany, Greece, and other nations
still much higher.
Smoking, as we shall see,
is a major global killer.
I'm not even going
to bother with that
because it's still indecipherable.
But what I've been trying to do
is to demonstrate
that we are applying
healthcare models
of another era
to health problems of today.
And I'm going to explore
in theme three
what are the limits to healthcare?
And I think the first limit
is that we are in all nations
starting to crowd out
other public expenditure
through the amount of money
that's being driven into healthcare.
We guess that in the UK
the demand for increased
investment in healthcare
which comes across as a result
of an aging population,
of a growth in population,
as a growth in the incidence
of long-term conditions
as opposed to episodic ill health
is in the region of 4-5% real
in terms of its impact upon demand.
So we're facing
in a stagnant economy,
a steady increase
in population demand.
There's also many other
less tangible drivers.
For example, public expectation.
Dr. Google has been
a tremendous help,
but Dr. Google results in
patients going to
tell their doctor
what's wrong with them
as opposed to
the conventional model.
And the overtreatment
and overmedication
that we see as
a consequence of this
is also driving cost.
Investment in drugs,
which is our budget
14 billion a year in England.
The budget of the organization
that I chair
is currently 8% of GDP—
It's 100 billion pounds—
of which 14 billion is spent on drugs.
But also high precision new equipment, MRI imaging
all drives up cost.
This figure from Massachusetts,
in case we think this is
a UK phenomenon
and not an American phenomenon,
demonstrates that even in
a wealthy state in the US
the percentage change in
spending in Massachusetts
between 2001-2015
has seen healthcare
as the only positive beneficiary
of state expenditure whilst
all others have been on decline.
Just think about this because
this has tremendous implications
for the way in which
we build healthy places.
If our money is going into healthcare
at the end of the health cycle
as opposed to investing in
prevention of ill health,
we're just putting money
in the wrong place
and it's a very deep hole.
And I just wanted to say a few words
about what we had tried to do
in driving through efficiencies
in England over the past four years.
As a result of the financial crisis
in 2008,
there has not been that 4%
annual real increase
in health expenditure.
We've been held down
to about 1.2% real
which is much more than many
other government departments.
The consequence is being able
to drive efficiency gains.
Efficiency gains and productivity
gains in the NHS
have generally been the order
of only 1% per annum.
I'm going to show you in
a moment how significantly
that has to change in the future.
But these are just some more data
as to what you can do
and even in a squeezed economy.
But our advantage has been
that over that period
pay restraint has driven down costs
because the pay in the public sector
has been above pay
in the private sector.
The curves are now intersecting
in the other direction.
And that soft cushion is
no longer available
for us to repose upon.
And this comes from a report
published just yesterday
just to show
just how up to date I am.
Just yesterday,
the Institute for Fiscal Studies,
which is the respected independent
economic commentator
in the UK
set out some of the options
for after the next election
which takes place on May the 7th.
All the parties, by the way,
are united in their affection
for the National Health Service.
All parties are united in committing
additional resources.
In fact, my role has been
to sit back and applaud
as each party tends
to outbid the other one.
But the problem is of course
those promises
bear no relation to the reality
of what will face
over the next five years.
And this, I think,
demonstrates really clearly
what the curve is.
If we were to maintain investment
at that point 0
on the bottom axis,
that is no real terms increase
for the NHS.
If we were secondly
to follow the commitment
of the two major political parties
can is to drive down
the continuing deficit
in the nation's economy,
that would result in approaching
a 6% reduction
in investment
in all other public services.
If we start putting in more resource,
you can see as the line comes down
towards the right-hand side
if for example just 2% starts
to drive out 7% investment elsewhere
and likewise down to 4%
drives out 8%
investment in other public services,
this is schools, libraries, research,
I mean, an enormous range
of other public goods
that are at risk
because of public demand
and the public popularity
and the salience
of the National Health Service.
And by the way,
to put this in context,
and in light of the slides
that I showed earlier,
this is one of the cheapest
health services in the world.
We are consuming only 8% of GDP
in the public contribution
and another 1.3%
of private contribution
which is principally chiropody,
physiotherapy,
over the counter medicines,
and a few private hospitals.
The system is over 90%
publicly funded.
And it's cheap.
It's dirt cheap.
It's really cheap, and it's great.
But anyway, hang on.
There we go.
So we have ourselves
started to think about
how we turn this around.
And what are the radical
reforms that are needed—
by the way, I should explain
that the board that I chair
was set up three years ago.
It's the first time there's ever been
an independent Board of Directors
at the National Health Service.
I use that word
"independent" loosely
because this is an organization
of huge political salience.
And our relationship
with political leadership
is affectionate.
[audience laughing]
It's not intimate.
[audience laughing]
And at times,
it's a trifle turbulent.
But the objective
and the point of this
is that for the first time,
the NHS leadership itself
has produced a view
of its future.
And this is so consistent
with the themes
that were going around this morning
because our view of the future
is that we don't produce
a national top-down plan
as to how care is to be
delivered in the future.
Our view is that we set out what
we think are better models of care,
models of care that
will be more efficient
and better wrapped around patients,
but that they will be
designed in localities
with our support and guidance
but not imposed from on high.
The truth is that the NHS
and the government
have a brilliant history of planning
and an appalling
history of execution.
I would hope that we could tick
the second box positive
on this time.
So against a forecast amount
of 3.5%,
we have been modeling
how to hold the cost
down to 1.5% real per annum.
And by the way, there are
different ways of measuring this.
One is to just look at GDP.
The other one is to look
at the cost per capita.
And this is why
some of the charts vary.
If you have a rising population
which is out of kilter with GDP
or if you have a rising or falling GDP,
then the figures
come out differently.
But what we want to do is hold
the cost of 1.5 real terms increase.
We calculate the difference 3.5.
Then by 2020,
we're 30 billion pounds short a year.
In other words, we'd need to raise
the public level of investment
by that and you saw
in my preceding slide
how that affects
the investment in other services.
This implies that we get 2% to 3%
efficiency gains out of the service
which is completely unprecedented.
We focus much more on prevention
that I'll come to in a moment.
And we focus much more on
taking care out of hospitals.
Hospitals are the most dangerous
places you could ever go into.
Please, don't go into a hospital.
People die—[audience laughing]—
in hospitals.
And hospitals, to be serious,
are the cathedrals
of modern science.
I mean, our best hospitals
are absolutely superb,
well-equipped,
fantastically well-trained staff.
But it's a misuse of their function
which is to treat
acute instances of illness
or injury or very rare conditions
where you need
highly specialized care
when that's not now
the major cause
of premature death
or high morbidity.
What we need to do
is to understand
how we keep people
out of hospital
and prevent them from accumulating
those disorders
which come from
the non-communicable diseases
that I've mentioned.
This is a major, major challenge,
and it's not one therefore
which is limited
to healthcare systems.
This is my point this morning.
We are running out
of healthcare
as the model to look after
the health of our populations.
So there's a triple aim
of how we re-design health and care
and this is actually
a combination of our thinking
with American input and support.
Looking at whole population health,
stuff that I'll come onto in a moment
around nutrition, physical activity,
the environment,
around poverty and around violence
and the causes
of ill health in populations.
We want to improve
the experience of care
in terms of safety.
Not all care is safe.
Not all practices are joined up.
It's quite common
in healthcare systems
to have mistakes.
One of the critical areas of mistake
is handover of care,
when it goes
from a primary physician
into a secondary physician
and into social care.
Many of our nations don't have
joined up electronic medical records.
The US is not
a high performer in this
despite its huge
technological base.
In the UK, we have almost 100%
of electronic medical records
in primary care
but only about 50%
in secondary care.
So the cathedrals of science
are the poor performers,
and the small corner shops
of primary care
are the high performers,
largely because of the way
in which we as a nation
have invested in their systems.
So we need much more
patient-centeredness,
timeliness and efficiency in equity.
I go over those quickly
not because they're
not hugely important,
but simply because
I want to get on
to where we really need to be.
And I'm going to move on.
Actually a small question,
who costs most?
Sorry. The line
along the bottom is age.
And the curve,
as you can see,
we spend a little bit of money
on people aged between 20 and 25,
but as you get to our age—
looking benevolently
around the room—
[audience laughing]—
there's quite a ladder actually
so it goes back
to my earlier theme.
We have a demography
in most of our countries
which are economically developed
in which the really good news
is that we're all living much longer.
This is fantastic news
by the way.
And one of the major contributors
has been the reduction
in smoking levels.
If you look at life expectancy
from 1908 until the mid 1980's
there were steady
but gradual changes.
The incidence
of smoking control
has actually ensured
that male life expectancy
has started to rise
and indeed in many countries
now is equaling
female life expectancy
where previously
there was a gap.
But life expectancy now
is into the 80's
in the UK and many
other developed nations,
a very significant increase.
But the cost of maintaining it,
as you can see,
it's rather expensive.
We calculate that we invest
about 80% of the cost
of any individual's
lifetime healthcare
in their last two years of life.
If only we knew when those last
two years were going to occur,
we could probably reduce that cost.
[audience laughing]
But one of the—
there is a really serious problem.
I do commend to you
the recent book by Atul Gawande
just called Being Mortal,
the US Surgeon General
from Massachusetts
in which he points out how much
wasted money goes
in to prolonging life
at the end of life in circumstances
not of peaceful and dignified death
but in circumstances
of aggressive treatments,
particularly for cancer
and for chemotherapy
and interventions
which is not so much
a technological issue
but is a very personal
psychological question.
What choice would we make?
And actually what choice
would we wish now to record
for our loved ones about
how we would choose to die?
But it's a phenomenon that is
becoming a global phenomenon.
So let me then
turn to this point.
I think that we have reached
the limits of healthcare.
Of course we can do a great deal.
We will continue to invest
in technologies.
Various things will occur in the way
in which healthcare is delivered.
But healthcare is not
solving the problems
of a healthy population.
And actually,
it's limited in terms of its focus
and it's limited in terms
of its affordability.
So how people live.
Actually it's not people.
It's you and me.
It's how do we
as individuals live?
How do we wish to live our lives,
and what is the leadership
that we can provide
to populations more generally?
I've taken a look
at the ULI's strawman
I've started to try to understand
what are the key themes
that you identify
in the real estate injury—
industry, not injury—industry
as the things
are going to start to change,
patterns of demand and markets.
And I've highlighted the key things
that seem to me
to be close parallels
with health systems
across the world.
Technology, supply and demand,
demographic changes
are going to critically affect
your industry and ours.
Movement of people and goods,
infrastructure hardware which I'll come back to in the health context,
our cultural and policy shifts likewise
virtual mobility of connections
and a very different demographic
interacting with your industry
and interacting
with healthcare systems
and the risk profile
of different cities.
Not every city
has the same demographic;
not every city
has the same health issues;
and not every city
has the same leadership.
We need, I think, to be far better
in attuning our thinking
about healthcare systems
and prevention
to the circumstances
of our cities.
So I've tried then
on the back of that
to make a list of what
I see happening in healthcare.
And if you can see it,
I would say failures of
the traditional models of care.
We have from—
we've put stuff into silos.
I mean, the Cabinet Secretary
in Britain
started talking about stove pipes
much to the confusion of everybody,
but a stove pipe
seems to be a very big silo.
And we have primary care
physicians over here,
secondary here, tertiary here,
we have social care over here
because that's the way
we did it in 1948.
And that was the way
which mapped on
to the demography
and to the health profiles
of our population in 1948.
You had a family doctor
who looked after you.
Medicine was not tremendously
advanced as a scientific pursuit.
It was possible
after a few years training
to run a small family practice
and provide generous
and benevolent care
to a family population.
Today it's completely different.
The limits of the knowledge
of a primary care practitioner
practicing across the whole
range of medicine is obvious
in the nature of current medicine.
So we need new models
of primary care
in which physicians come together
and provide multispecialty provision
because you know
our new health conditions
are not unitary.
If you look at term,
for example, diabetes,
type II diabetes which is closely
correlated with obesity,
we find that we need specialists
across an array of things.
We need specialists
in diabetic retinopathy;
we need specialists
in nutrition in diet;
we need specialists
in some of the problems
which come as a consequence
of limb loss
and sometimes heavy amputation
of lower limbs
amongst diabetic patients.
So it needs both specialism,
but multi-specialism,
multidisciplinarity in place
of single general care.
I think that the next
set of revolutions
is going to be around
personalization of medicine.
At the moment,
the pharmaceutical industry
is heavily dependent
on blockbuster drugs
which work for about one-third
of the population on average
to whom they're administered.
And that one-third—
frankly all the population
to whom they're administered,
the compliance rate
is probably about 60% anyway
on the medication.
So there are probably more drugs
that are flushed away
than are actually consumed
by the population.
But the very important model
for pharmaceutical industry
is to ensure that the product
induces a system
of daily consumption
of the product over a long period.
The big challenges to that,
I think, first of all
are our ability now
to attune pharmacy
to the genetic profile of individuals.
A second one is
the emergence of curatives,
in other words,
a product that you take once
and it cures the condition.
This is starting to come through,
but we're starting
to see headline pricing
of half a million pounds
per patient for something like this
because somehow the cost
of research and development
needs to be picked up.
It takes a billion pounds to bring
a new drug onto the market.
You need to find
a pricing policy
that allows it to be recuperated.
But of course there's a bell curve
between our cost and use,
and assumption that
a healthcare system
that doesn't provide such drugs
is a harbinger of death
and is rationing life
to individuals.
So we're seeing much
more personalization.
Data and digitization.
Healthcare systems
have phenomenal data.
And the emergence, I think,
of new products
from Apple and Google
of wearables,
of the new iWatch
will mean that data
is going to become available
much more broadly than within
the form of healthcare systems .
And that data
has immense value.
We are at the moment
trying to bring together the data
of 55 million patients
across all facets of health provision
which will allow us
for the first time
to stop flying blind
and how we condition healthcare
but to understand what it is
in different communities
that is causing different conditions
and what treatments
today's conditions are
bringing about what outcomes.
So you could actually envision
having an epidemiological real time
clinical trial across
an entire population.
It's there.
It's just that our data analysis
doesn't yet allow us
to do it fully.
Digitization equally is going
to transform all of healthcare.
And I will I think combine
that with miniaturization
and personalization.
We anticipate that
the future would involve
particularly with Generation Y
an access to healthcare
that is mobile
and will use apps.
There are already apps available
where you can,
for the price of
a cappuccino a week
dial and talk to
a general practitioner.
That will become
a 24-hour service,
service by general practitioners
around the world
and with its own
access to prescription,
immediate pushing of a button,
go to the pharmacy,
pick up the prescribed drug
or reference to
a secondary care provider
to a specialist.
This is real time.
This will occur,
but it will be I'm sure
a generational thing.
Miniaturization we already see,
for example ultrasound
which used to be
a very large piece of kit
now being handheld
that can be taken out
into the villages of Africa,
no longer tied to a major hospital
MRI similarly not yet handheld
but will be reduced in size.
So a lot of the heavy kit
previously essential,
previously confined
to large and expensive
hospital premises,
you can foresee
will become more flexible.
People are already
wearing wearables
which monitor blood pressure,
which monitor sugar levels,
which monitor exercise.
Most people in this room
are probably wearing one of those.
And that's just the beginning.
So we'll see a large change
in the ability
of individuals to take responsibility
for their own health.
The risk of course is that
this will not be something
that will spread uniformly
across populations.
Intelligent audiences
such as this one
will of course be
in the vanguard.
The efficiency crunch.
Almost any industry
that you can think of
has been through a radical change,
a radical crunch to efficiency.
Healthcare is the one that efficiency
has so far bypassed.
Healthcare is the one
that actually digitization
has largely bypassed.
We are not the focused
technologically-driven industry
across the world.
This is a global phenomenon,
a global phenomenon. It goes back
to what I was talking about before
in terms of the affordability
of healthcare.
We know
that we could drive out
20 or 30% of the costs.
One of the leading US analysts
has estimated that
within the US model
34% of cost
could be taken out
without any
harm to patients
or their treatment.
Right.
So this is a slide
that simply shows you
something about
the safety of healthcare.
What I've tried to do here is
to demonstrate people die
and they die in cases where
if healthcare were better-organized
and safer, they would have lived.
The distance between
the two bars in each case
you'll see that they're
organized by nationality
and the difference between the two
is the improvement
since 1997-98
to 2006-07.
So we are bringing down
mortality amenable to healthcare
but actually in these
highly developed nations,
things are still going wrong
and they are things
which need to be put right.
So let's get real.
Where's the actual
contribution of healthcare
to the health of a population.
We would guess that
your genes actually is 50%.
It's what you're born with.
I don't just mean genetic inheritance,
but the unique genetic structure
of every one of us.
And actually we know
very little about that.
We're just launching in the UK
a major program we will be doing
whole-genome sequencing
of 100,000
and taking the data of that,
concentrating on cancers
and on rare diseases
which do have a large hereditary
and genetic component
to try to understand
the underlying genetic
characteristics of disease
that will be a further transformation
but at the moment,
we don't know.
We think that 50%
is stuff that is territory
yet to be explored.
And healthcare we think
is probably 10%
in its contribution
to the health of populations,
about 10%.
And what's the rest?
Well, it's other stuff.
[audience laughing]
And other stuff
is what we're here about.
It's other stuff.
It's the way we behave.
So I'm going to then turn to
some of the themes around
city planning and health
and what we need
to be worried about
under other stuff
and the contribution
that this industry
is capable of making.
Just allow me to go back
to the intellectual origins of planning.
It actually was about this stuff.
Ebenezer Howard
was about other stuff.
What Howard had wanted to do
was to depopulate
the slums of urban Britain
to provide green fields
in which populations
could grow
and reproduce and develop
and in which
the suburbs could grow.
So Howard, the great intellectual
pioneer of urban planning
was a man around other stuff.
But how people live
is still a combination
of a variety of factors. There is that
which others do to us.
And this slide of Beijing
I think is extremely telling
and anybody who's been
to Beijing in the last few years
knows you can't go outside
without your breath being caught
as you walk around.
That estimate of China losing
between 350,000
and a half a million people a year
is from Chen Zhu,
the recent Minister
of Health in China,
not some sort of international critique of China.
It's a simple realization
that actually there is a problem.
We're killing people
by providing urban areas
heavily industrialized
and with particles in the air
that bring about premature mortality.
But there's something else
amongst the other stuff.
And that's the repeat
of the early one.
It's the incidence of obesity.
As I mentioned earlier,
the incidence is
uneven across nations
but the one thing
that is common is the trend.
The trend line is upwards.
And the most frightening
part of it is children.
The incidence of childhood obesity
is a true obscenity.
This slide demonstrates
we think at the moment
about approaching 7%
of the world's children
under 5 are overweight or obese
and the proportion of them
by the age of 11
that are obese in the United Kingdom
rises from 10% to 20%.
So our children
are going into school
not so fat,
and they're coming out fat.
So there's something
going on there.
And children of all ages
are twice as likely
to be obese
in the most deprived areas
as in the least deprived areas
as that chart demonstrates.
So what are we doing?
Are we actually lining up
for our children and for the future generations
a life of low level of physical activity,
a life of high risk of disease,
of cardiovascular disease,
of type II diabetes,
of amputations, of blindness
because we're failing
to take action.
We're failing to think
in everything that we do
including the design
of real estate
about how we promote
the things that will change that.
We know a number
of the reasons why
is access to food,
plentiful and cheap and fast,
and it's access to screens,
the substitution of gaming
with fingers and screens
as opposed to gaming on playing fields.
It's the loss of playing fields.
Many playing fields
have been taken from schools
and have been used for development
in the UK and I'm sure globally.
There's a multifactorial set of issues.
Just look at some figures
which come from
the Boris Johnson's
Commission on Health
which reported last year.
We know that actually
the proportion of people
who are taking daily exercise
is pretty low,
and this is the adult figures.
And it actually varies
reasonably significantly
between different boroughs.
The curious bit
about this figure for London
is that it's not correlated to wealth
in the boroughs.
Nor is it correlated to whether
a borough is an inner city
where you might think people
were more concentrated
in their apartments
or an outer city
where people have
more green space to walk around.
So there's something going on
around physical exercise
and physical activity.
Here we have a similar figure
from the same report
relating to exercise
by children in London.
And the highest proportion,
above 60% of children
attending a state school
who get three hours at least
of high quality physical education
in school sport
within and beyond the curriculum.
It's highest in wealthier bureaus,
Hammersmith and Fulham,
Kensington and Chelsea.
And yet even in Hackney
which is a very mixed borough,
is down to 40%.
So it's falling away
in different parts of the city.
So real questions here.
What is it about
those parts of the city?
Is it their layout?
Is it their leadership?
Is it their educational system?
Is it the culture?
What is it that causes people
to behave in different ways?
And these are fundamental questions
for your and our leadership
for the future.
So then physical inactivity.
By the way, going back to
the McKinsey's Global Initiative
report on obesity,
they would argue that interventions
to bring down rates of obesity
probably amount to about 42
of which physical activity
is relatively low on their list
which I think is
a very interesting point.
So physical activity
is much more related
to these other types of disease,
but actually it's in terms of obesity,
it's portion control
which they would put
at the top of the list
and regulation of food industry
and sugar and salt
and the other
familiar interventions.
But we understand that
for coronary heart disease,
something like 6%
of death and morbidity
is caused by physical activity,
strong correlation
to type II diabetes
but up to 10% in the case
of breast cancer
and in the case
of colon cancer.
The figures and brackets beside these
are a range which relate
to different countries.
But the trend you'll see
is completely consistent.
And on life expectancy,
who's dying?
Well, 9% of premature mortality
is caused by physical inactivity,
5.3 million people
across the globe every year.
And if inactivity decreased
by 10 or 20%,
we could save half a million
or 1.3 million deaths.
This figure just gives
a global indication
of who's getting physical activity
and who is not.
Let me press on.
So magic bullets.
They don't exist.
This slide's a mock up.
[audience laughing]
I have been searching for one
but without success so far.
This is a hugely complex area.
It's how human beings
relate to each other
and how human beings
relate to the environment
in which they live.
But there is some interesting
lateral thinking.
This was profiled recently
in the Guardian newspaper.
This is the Mexican Tube Station
where if you want,
you can ride for free
on the Tube in Mexico City
if you do ten squats
in front of this machine.
[audience laughing]
Ten squats, it knows—
it's faithfully recorded,
and you get a free ticket
to allow you
to ride on the subway.
We're going to introduce this
compulsory across London.
The speculation is how long
before you get an arbitrage,
you have a willing squatter
jumping up and down for you
and they get paid a discount on the full headline price of the ticket.
But this is fantastic,
but actually just think
of the lateral thinking about this.
How do we build in the need
for physical exercise
in mundane tasks
around the country?
I've had recent discussions
with London Underground
who have this concern
that people are using the Tube
to travel a journey which might take
five minutes on the Tube,
and the walk is just 200 yards
because our Tube map is so stylized
that you can't quite tell what's
the physical distance
between different stops.
So we just need to get people
out onto the streets
and I think much more collaboration
with systems of public transport
and as you've been talking
about this morning,
reduction in private car parking,
the modal shift
between modes of transport
to promote physical activity.
And then we have smoking
which is a major killer.
I just cannot stress
how much damage
this causes to peoples' health.
80% of lung cancer
relates to smoking.
And lung cancer
remains a major killer.
It's a very nasty, unpleasant,
and largely incurable condition.
Public health campaigns—
the photograph there comes
from a public health campaign
in the 1970s,
hence the young man
who's very smart
is wearing a bowtie
which you don't
commonly see nowadays.
It may—I'm sorry Mayor.
[audience laughing]
[applause]
But he' a young man.
[audience laughing]
So plain packaging then.
Shall I move on quickly?
[audience laughing]
So the UK is going to introduce
plain packaging of cigarettes,
but do you know,
there's nothing
that excites young men more
than something that's
made even more dangerous
by the fact that their government
wishes to wrap it up
in plain packaging.
So a big problem
as with childhood obesity
is young adoption of smoking.
And there's a very strong
socioeconomic relationship here.
Smoking even with a high taxation
is something which is highly
correlated to poverty
poor education
and poor living conditions.
Bans in public places.
Again, I think here is an issue
for the industry.
The recent report
to Boris Johnson
has proposed smoking
should be banned
not only in all the places
where it presently is
but in Trafalgar Square,
Parliament Square,
and all public parks in London.
Boris' response was
this is a nanny state.
Well, nanny was sometimes right.
I mean, I didn't have one,
but I've read the books.
The issue has to be that
it is a nanny state
when politicians do it.
There's a libertarian argument which needs to be listened to and heard.
When clinicians say it—
when this is an argument
put forward by clinicians
and clinicians need to be upright
and be out there and to be saying
to people this is your choice.
And do you want to live long
and have grandchildren,
or would you want to die
not only of lung cancer
but of horrific
constrictive pulmonary disease
and bronchial blockages
and everything else?
But let me turn to
my favorite subject now
which is the aging population.
Here I want also to think about
what are the issues
for a real estate industry?
Do you know we have 380,000
elderly people suffering falls
in England every year.
Commonly, they'll be taken
into the emergency room
Commonly—by the way,
30% of dementias
are diagnosed in the emergency
room for the first time
because people commonly—
this is a common condition
have suffered fall,
brought to the emergency room,
there is some confusion.
They cannot then be returned
to their home because
the home is not adapted
properly for living by somebody
who's suffered a fall
and who has dementia.
So very interesting discussion.
Did you know that the
rate of domestic fires
burning down houses
has come right down like this.
And the reason is the fire service
now pay visits to homes.
They go around and they advise
householders on installing fire alarms
on dodgy electrical equipment,
on things which are
too close in proximity
and on the dangers of smoking.
We are now working with them
to try and do exactly the same
in visiting the homes
of elderly people.
The rugs, the slippers,
the absence of a handrail
on the stairs.
If we can stop people falling
in the first place,
then we keep people
out of hospital
and we keep them home
independently for much longer.
And then the last issue is dementia.
Can I just stress that there
isn't a thing called dementia.
There are many conditions
which add up to types of dementia
which Alzheimer's is one.
But with an aging population,
inevitably the incidence of dementia
will rise. My scientific colleagues
at UCLA
assured me if you live long enough,
you're going to get dementia.
That's unprovable, of course.
But it's an interesting proposition.
We know that we across the world
will have 65 million
people with dementia by 2030.
We'll have a million—a million—
in the UK, out of 60-odd-million.
It's costing us 23 billion per annum.
And that's not just healthcare
but social care
and also the unacknowledged costs
on families and carers
which don't enter into
the national accounts.
So I will press on through this,
but I think everybody understands
the theme of dementia.
So what I'm just going to do
is to propose where planning
cities in good health
sit in the 21st century.
It's inevitable, isn't it, that health
and the population's health
have to be built into every
decision that you take
around investment in real estate.
You are the leaders,
and these are the problems.
We've got a healthcare system
that no longer is providing
what it used to be able to provide
because the shift in the character
of ill health of the population
has been profound and irreversible.
Secondly, it's about human behavior
in which there is a need to provide
guidance, nudge, and support.
And the support that we need
is not just for physical health
but for mental health.
We see the incidence
of mental ill health
also rising steeply
as a consequence of stress
and a teenage population's
evidence through eating disorders
and often through misuse of drugs.
Smart housing for health
is just a necessity,
building into housing the needs
of a changing demographic.
Some of this will be portable
electronics that can be changed.
The fridge, for example,
it sends an alarm to a family
if the door isn't open
before 9 o'clock in the morning
in an elderly person's home.
The fridge that dispenses medication
and oversees the independence
of the individual.
We need extraordinary rigor in our evidence metrics and monitoring
around reduction in emissions,
around food quality,
promotion of physical exercise,
and demographically aligned
housing models
for independent living.
That is just a very brief agenda.
Let me stress where we are at this
beginning of the 21st century.
We have a growing population.
We have an aging population.
We have a health system
that is buckling
in every country in the world,
but the health system
is catering for 10%
of the ill health of the nation.
We will,
over the next decade or two,
crack into the genomics
and the genetics of ill health
that may expand that 10%.
But the other stuff is still
the stuff that matters.
The other stuff falls beyond
the formal limits
to the healthcare system
but solving it is critical
to our solvency
and to our performance
over the coming years.
Thank you.
[applause]