Towards personalised prevention? The new Green Paper on public health
22 July 2019
In the final hours of Theresa May’s term as Prime Minister, the government has released a new Green Paper on public health for consultation, Advancing our health: prevention in the 2020s.
Firm foundations for better health
The report points to the substantial improvements in health outcomes arising from public health interventions, but noting that progress has slowed in recent years and that significant challenges remain. It says that good health is not something to take for granted, but rather ‘an asset to invest in throughout our lives’, saying that the government will ‘lay the foundations for good health by pushing for a stronger focus on prevention across all areas of government policy’.
Whilst firmly acknowledging the importance of tackling environmental and social causes of ill-health, and of interventions in the early years to reduce the risks of subsequent problems, the report also suggests that a new personalised prevention model offers the opportunity to ‘build on the success of traditional public health interventions’ and tackle new health challenges.
What is personalised prevention?
The concept of personalised prevention, long espoused by the PHG Foundation and formally set out in the Chief Medical Officer’s Generation Genome report, is firmly embedded in this preliminary policy paper.
In essence, personalised prevention refers to efforts to prevent disease at the level of the individual; this complements rather than to replaces classic, population-based public health efforts, but recognises that the most accurate and effective predictive prevention for an individual is based on their unique biological, environmental and behavioural risk factors, and their personal situations, preferences and drivers. Biological risk can be assessed using genomic and other biomarkers.
However, in practical terms, personalised prevention may also refer to ‘somewhat more personalised’ or stratified prevention – using biological as well as other risk factors to refine a wider population into sub-groups and target preventive interventions appropriately to those at higher risk.
The Personalised Prevention chapter of the CMO’s report, written by PHG Foundation chairman Dr Ron Zimmern, called for three actions from policy-makers:
- Ensure that the NHS prioritises prevention and places citizens and patients at its centre, managing their care according to both their biological risk and personal wishes and values
- Establish systems to collect, share and use individual data to allow stratification of people into groups according to their biological and environmental risks of disease
- Consider how personalised prevention can be most effectively and efficiently delivered via the public health and clinical workforce, including whether a formal field of preventive medicine is needed
This new government paper makes significant steps towards addressing at least the first two of these three actions.
Preparing the way: intelligent public health
Advancing our health sets out a vision whereby the 2020s ‘will be the decade of proactive, predictive, and personalised prevention’ in the form of personalised advice and care. It forsees a ‘new wave of intelligent public health’ whereby data generated both within the NHS and via wearable devices will not only enable precision medicine, but also be available to individuals to help tailor their own preventative care and make them ‘co-creators of their own health’. It also expects that genomics and other technologies such as artificial intelligence will help to embed prevention from and even before birth, for example enabling prenatal disease diagnosis and treatment.
Public Health England (PHE) will work with NHSX and other partners on innovative projects to evaluate and model Predictive Prevention including the concept of and evidence base for personalised prevention, analyses to help understand and support the most vulnerable groups, and building public trust about data use.
The NHS will also develop intelligent screening – incorporating genomic and other data into risk assessments to stratify populations more accurately and target interventions towards those at greatest risk (for example, using genomics to identify people at high risk of cancer). Importantly, this includes a commitment to faster implementation of recommended interventions developed in a more coordinated fashion between relevant agencies such as NICE and the UK National Screening Committee.
The role of polygenic risk scores
In looking to harness genomic information for risk calculation and predictive prevention, the paper underlines a clear and wholly understandable interest in polygenic risk scores (PRS), sometimes also known as genomic risk scores (GRS), as potential complements to existing risk assessment tools. The hope is that these scores could identify invisible populations of people at significantly increased risk of common diseases such as cancer, heart disease and dementia, who are not identified by current risk assessment measures.
With this in mind, the paper announces a new Accelerating Detection of Disease challenge to support research, prevention and treatment of major chronic diseases and mental health conditions. This will combine the NHS, major charities including Cancer Research UK, the British Heart Foundation and Alzheimer’s Research UK and industry, as well as the UK Biobank and (presumably) existing plans to sequence at least one million human genomes and create a cohort of ‘genomic volunteers’. This is now said to include using these data to develop and improve the evidence base for the use of PRS, a worthy aim – and to ‘offer as many participants as possible their PRS’ – possibly less wise if this means giving individuals their risk scores ahead of this large-scale evidence base.
Realising the grand vision for better health
Views on how to ‘help people live healthier, happier lives for longer’ as set out in the Green Paper are sought, with the consultation open until mid-October. Having taking these submissions into consideration, a formal government policy White Paper would be expected to follow. Naturally, this may take some time, as no doubt the volume and breadth of responses and evidence to the paper will be significant; there is also the potential for policy change with a new Prime Minister at the helm.
However, the PHG Foundation is strongly supportive of the vision of the report and particularly the acknowledgement that genomics and other technologies – and their essential counterpart, big data and analytical tools including AI – can and should play a vital role in offering more personalised, and ultimately more effective, prevention of disease. This in no way diminishes the importance of tackling the wider environmental determinants of health – clean air and water, decent housing and diet, work and education and so on – nor the valuable public health approaches such as screening. Rather, in the spirit of the discipline of public health genomics co-founded by the PHG Foundation, it recognises that science, whilst no magic bullet, can genuinely help deliver better health.
Forthcoming PHG reports to be released early this autumn will examine important issues that should make further contributions to these endeavours to support personalised prevention. The My Healthy Future project will offer a whole range of evidence on the potential future applications of science and technology for prediction, prevention and management of health, and their wider implications for policy-makers. Our report on polygenic risk scores will summarise the current state of knowledge with respect to this exciting field, and highlight those areas where further evidence is needed.