Building Healthy Places with Sir Malcolm Grant of the National Health Service of England

- 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]