Dr Adam Giangreco, Director of Innovation and Commercialisation;
Dr Leah Macaden, Senior Lecturer in Nursing (Care of the Older Adult, Dementia Education and Research), Department of Nursing & Midwifery;
Dr Mark Grindle, Senior Lecturer in Digital Health, Division of Rural Health and Wellbeing;
Dr Sarah-Anne Muñoz, Head of Rural Health, Division of Rural Health and Wellbeing;
Professor Trish Gorely, Professor in Physical Activity for Health, Department of Nursing & Midwifery;
Professor Gill Hubbard, Professor in Behaviour Science, Department of Nursing & Midwifery; and
Professor Sandra MacRury, Head of School of Health, Life Sciences and Social Care, Professor of Clinical Diabetes, Division of Rural Health and Wellbeing and Consultant Diabetologist and Endocrinologist, NHS Highland
The Institute of Health Research and Innovation at the University of the Highlands and Islands comprises a team of over 70 academics, postgraduate students, research fellows, and technical support staff. Research is approached collaboratively and holistically via multidisciplinary teams and involves NHS Highland clinicians and allied health professionals, local businesses and third sector organisations, and national and international collaborators. Projects address qualified unmet clinical, social and economic needs and aim to deliver wider societal benefits including improved population health and wellbeing.
Healthy ageing research is a major focus of the university given the high percentage of older residents within the Highlands and Islands. Our purpose in responding to this parliamentary inquiry is to emphasise the importance of considering healthy ageing in remote and rural communities, where endemic physical and social isolation, under-education, poor connectivity, and socio-economic deprivation are associated with a high incidence of age-associated morbidities.
Introducing new interventions and technologies to improve health span must consider the challenges faced by remote and rural communities when designing, developing, and delivering solutions to improving health outcomes. The university investigates ageing as a lifelong process, incorporating factors such as genetics, diet, lifestyle choices, socioeconomic deprivation, social isolation, influence of environment, connectivity, and infrastructure in all projects. We believe this holistic approach is needed to meaningfully address and improve health span outcomes throughout the UK and worldwide.
Answers to questions
1. How complete is the scientific understanding of the biological processes of ageing and their epidemiologies (including the relative roles of genetics, epigenetics, lifestyle, environment, etc.)?
Our scientific understanding of the biological processes of ageing has advanced significantly in recent years, with major advances in fields including genetics, cellular senescence, and epigenetics. In addition, research has increased our knowledge of the roles played by diet, exercise, lifestyle choice, environment and infrastructure. Unfortunately, these advances have not resulted in increased health spans in developed countries, with recent trends notably showing reduced average life expectancies in the United States.
The global incidence of chronic age-associated diseases such as chronic obstructive pulmonary disease, diabetes, dementia and heart disease can be twice as high in remote and rural areas such as the Highlands and Islands due to factors including socioeconomic deprivation, geographic and social isolation, inadequate primary and secondary healthcare facilities, reduced public services, and lack of high quality education. Therefore, by investigating the impact of unhealthy ageing in these remote and rural geographies there is the potential to deliver proportionally greater benefits than in other regions. Healthy ageing also needs to be understood in the context of genetic, lifestyle, environment and socio-economic determinants across an individual’s life course. There remains a paucity of evidence and research using a life course approach to healthy ageing within a rural and remote context. The University of the Highlands and Islands is well positioned to explore this.
Healthy ageing research at the University of the Highlands and Islands covers a range of disciplines, from genes through to environment and infrastructure (see Figure 1). Our holistic approach investigates how relationships between an individual's genetics, epigenetics, lifestyle choices (inclusive of diet and physical activity), physical and mental health and wellbeing, environment (pollution, access to nature, social isolation), and infrastructure (public transport, access to primary and secondary care, connectivity) impact ageing outcomes throughout life.
Figure 1. Ageing research at the university covers a range of disciplines.
Historically, the Highlands and Islands have played a major national role in identifying and implementing novel technologies and innovations that impact health span. In 1913 the Dewar Report established the Highlands and Islands Medical Service, forerunner to today’s NHS and the world’s first public health body. The Service recognised the need to address health disparities in their wider context, by supporting funding for new road infrastructure, the provision of education resources for clinicians and allied health professionals working in remote and rural areas, and subsidies to offset regional economic disparities. It was only by addressing these issues collectively that the Service was able to improve the region’s health.
2. How firm is the scientific basis for public health advice about healthy lifestyles as a way to increase health span, including physical health and mental health? a. What are the practical impediments for this advice being acted on? b. Are there examples of good practice in the UK/devolved nations, or elsewhere?
Although significant understanding of the biological process of ageing now exists, significant gaps remain in effectively implementing this knowledge to increase health span. Within remote and rural areas such as the Highlands and Islands these gaps include the following:
1) A lack of addressing holistic considerations needed to realise improved healthy ageing outcomes. This necessitates looking beyond healthy ageing as a simple biological, physical or mental health concern, and considering wider aspects of society including interactions of people with technology, access to high-quality environments that promote healthy lifestyles and physical activity, and the impact of adequate public infrastructure (transport and connectivity). In addition, this holistic approach must consider ageing as a process that occurs throughout one’s lifespan.
2) A failure to engage with communities and individuals at increased risk of unhealthy ageing. These include remote and rural communities, groups and cultures experiencing social and physical isolation, and people from socioeconomically deprived backgrounds. The geographic availability of both healthcare resources (such as primary and secondary care facilities) as well as health promoting environments such as shops that stock fresh foods, and leisure services such as swimming pools and sports centres, has a direct influence on a region’s health span. In addition, in areas where there is little public transport provision and inadequate access to leisure services, a top-down advice-based approach to encouraging ‘healthy living’ is simply not effective, with solutions requiring an integrated approach.
3) Insufficient personalisation strategies for addressing unhealthy lifestyle choices and amongst individuals. There is a need to implement a ‘personalised healthcare’ style approach to tackling this issue, in contrast to the current ‘one-size-fits-all’ model of healthy ageing. This personalisation is particularly important when considering the diverse geographical, cultural, and socio-economic contexts of an ageing society.
To address these issues the government must think strategically about resource allocation, using a combination of technology, self-management, and community-based services. At the University of the Highlands and Islands, our focus has been on the development of evidence-based approaches to improved healthy ageing. Recent examples include the following:
Successful implementation of developments in healthy ageing will require a focused testbed approach, involving communities in which they can be adequately assessed and evaluated prior to implementation. This approach is based on the Framingham (USA) population monitoring study which has delivered countless health innovations since its inception in 1948. Remote and rural communities such as those in the Highlands and Islands represent an ideal location for equivalent long-term, intergenerational studies in improving health span given the region’s population demographics. These could involve a family-centric approach, integrating the experiences, values, and cultures of younger and older residents alike in new health innovations. Such a testbed approach would allow for evaluation and testing of novel interventions in a defined region prior to national and global implementation, whilst enabling iterative refinement and improvement at a rapid pace.
3. Which developments in biomedical science are anticipated in the coming years, in time to contribute to the Government’s aim of five more years of healthy and independent life by 2035?
The University of the Highlands and Islands recognises the role that patient-led care will have in improving health span, with an increased shift in responsibility for health outcomes from medical professionals to individuals. Developments in biomedical science that will accompany this shift include the growth of precision medicine based on an individual’s genetic and epigenetic susceptibility and sensitivity to treatments (rather than one-size-fits-all interventions), point of care and at-home diagnostics based on robust and clinically actionable biochemical and physiological biomarkers, and machine learning / big data resources that provide meaningful, clinically actionable insights (such as those that integrate physiological and biochemical biomarkers with other data sources).
It is essential that these improvements in biomedical science work alongside health and wellbeing initiatives that reduce social isolation, provide access to high-quality green and blue space, and increase the uptake of positive physical and mental health activities. We anticipate this be achieved through increased social prescribing focused on both self-management and non-pharmaceutical interventions. This approach should be enabled by developments in biomedical science and evidenced through robust, peer-reviewed clinical trial-like studies.
4. How complete is the understanding of behavioural determinants and social determinants of health in old age, and of demographic differences?
The university recognises that ageing is a holistic process, of which no single aspect can be considered in isolation. Success in improving health span therefore requires integrating a variety of genetic, physical, socioeconomic, behavioural, and social determinants of health. These must be considered at regional, local, and individual levels. At present, the knowledge base around principal determinants of health behaviour change in older adults is weak, especially when considering the heterogeneity of health status, culture, and life experience within populations. Thus, we consider that additional population-level studies will be required to enable enough personalisation of government-led initiatives to promote positive health outcomes amongst people regardless of age, experience, socioeconomic status, education, or geography. We anticipate this understanding will form part of the proposed Framingham-style testbed approach described in Question 2.
5. What technologies will be needed to facilitate treatments for ageing and ageing related diseases, and what is their current state of readiness?
The University of the Highlands and Islands believes that new technologies are one component of a holistic approach to delivering successful improvements in health span. Technologies will only be effective in the context of an increased acceptance of one’s individual responsibility for health self-management. In this regard, technologies that enable, promote, and facilitate individuals to accept increased responsibility are key. These may involve a combination of data-driven clinical diagnostic, medical, and consumer products such as foodstuffs and clothing, technologies such as wearable or other physiological monitors such as fitness trackers, or cloud-based computing algorithms that integrate large datasets to identify those at risk of poor health. It is critically important that any new technology enables delivery of meaningful, actionable health data for the user and, where appropriate, the healthcare professional.
In some instances, technologies will be envelope-pushing advancements in data science, genetics, or chemistry. In other instances, they will not. For example, improving street lighting in a region might encourage more walking and reduce the incidence of petty crime – thus leading to indirect ageing health benefits. In this regard, technologies can include relatively straightforward innovations so long as they are considered on a holistic basis.
Importantly, the development of any health, wellbeing, and lifestyle technologies are by no means solutions on their own. Appropriate engagement and collaboration amongst all stakeholders in the conceptualisation, design, and development of new technologies using public-patient involvement principles is essential to their success. These human factors-driven technologies must address considerations of ownership, autonomy, and mastery, whilst enabling the inevitable need for continuous improvement and refinement and protection of the individual’s right to privacy and security.
6. What technologies will be needed to help people to live independently for longer, with better health and wellbeing? What is the current state of readiness of these technologies, and what should be done to help older people to engage with them?
The University of the Highlands and Islands contributes to the assessment, development, and validation of technologies that empower people to live longer, healthier, and more independent lives in the place of their choosing. Importantly, these technologies are not limited to devices for the individual but include those that deliver improved communications and accessibility for entire regions and communities. Each project has user-led, collaborative design and development at its core, ensuring that each works positively for the person, healthcare professional, and wider community.
As an example, our work on the FIT House project demonstrated that adaptable, technology-enabled housing may play a part in allowing people to live independently within their communities for as long as possible. We worked closely with a range of tenants in new, smart homes to understand the impacts of this new type of housing from their perspective. Our work showed a significant social return on investment can be achieved through smart homes. We found these smart homes facilitated the formation of social bonds with other tenants within the scheme – something that can support independent living and alleviate loneliness and its associated negative impacts on physical health and mental wellbeing. Our work suggests that tenants and family members alike are happy to have sensor technology within the home – they can see the benefits of such monitoring and are happy for data to be collected, transferred and viewed. A key to the success of this project (and those described in question 2) was the holistic consideration of how each technology impacted and influenced other elements of users’ lives. Part of this holistic approach included careful selection of testbed regions that covered a range of geographies, socioeconomic groups, and clinical needs that were representative of the population for whom the solution was being developed.
7. How can technology be used to improve mental health and reduce loneliness for older people?
Technology comprises part of the holistic approach needed to effect improved mental health and reduced loneliness for older people. Research led by the University of the Highlands and Islands includes the design and evaluation of novel technology-enabled social housing schemes (such as the aforementioned FIT House project), evaluation of the Men’s Shed initiative for improving mental health and wellbeing, and recent engagement with region-wide connectivity and infrastructure programmes supported by the Inverness and Highland City-Region Deal. In addition to health and wellbeing benefits, these initiatives aim to enable older adults to positively contribute to their communities for longer.
8. What are the barriers to the development and implementation of these various technologies (considered in questions 5-7)? a. What is needed to help overcome these barriers? b. To what extent do socio-economic factors affect access to, and acceptance of, scientific advice and use of technology by older people and those who care for them?
Barriers to the development and implementation of technologies to improve health span result from failures in considering the holistic needs of all stakeholders. These typically include a lack of engagement with end-users in technology design and development (inadequate public-patient involvement, or a lack of user experience testing), insufficient research prior to technology development (resulting in tech-push, or solutions that do not address core problems), and a failure to consider the wider contextual needs of any given technology (including factors external to the technology itself, such as gaps in wireless connectivity rendering ‘smart’ internet of things devices unusable). A further barrier that often impacts the successful implementation of technologies is a lack of health economic and regulatory considerations, including a failure to understand the payor landscape, regulatory approval process and timescales, or clarity regarding the cost-benefits of any given innovation. It is only through considering all these factors that these barriers can be overcome and avoided.
9. What opportunities are there for industry in the development of new technologies to help increase health span? In which areas of medical research and technology development does the UK excel?
The ageing population is the next great economic opportunity, and industries that develop usable, effective products that promote improved health span will be in a very strong position to capture this emerging market. Benefits are likely to include the development and successful commercialisation of new products and services, investment in local, regional, and national infrastructure, and accompanying new job creation.
10. What more is required for the UK to benefit from commercialisation of its discoveries and inventions relating to healthy ageing, as envisioned by the Government’s Industrial Strategy?
There is a need to validate the usability of technologies to promote healthy ageing, via a process of collaborative design and development with all stakeholders. This must include the following groups: patients, allied health professionals, clinicians, community care workers, family carers, third sector organisations, public and private industry, as well as local, regional and national government representatives. Support for the establishment of dedicated testbed regions is needed to enable this collaborative and iterative technology design, development, and validation process. These regional test beds should also be representative of geographically and socioeconomically diverse populations for whom the technology is being developed.
11. How feasible is the Government’s aim to provide five more years of health and independence in old age by 2035? a. What strategies will be needed to achieve the Government’s aim? b. What policies would be required, and what are their potential costs and benefits? c. Which organisations need to be involved? d. Who should lead the work?
Targeting geographic and socioeconomic groups that are disproportionately affected by ageing and age-associated morbidities will have a greater impact and therefore proportionately greater benefits in improving UK-wide health and independence by 2035. Targeting these selected regions and groups will also facilitate test bedding of the new technologies and innovations needed to deliver improved ageing outcomes. A holistic approach involving all stakeholders and with collaborative and user-led design principles at its core is essential. Careful monitoring and collection of data coupled with appropriate health economic evaluation and modelling is also necessary.
12. To what extent are inequalities in healthy ageing, as well as differences in acceptance of technologies, a barrier to achieving the aims of the Government’s Ageing Society Grand Challenge? a. To what extent could achieving the Government’s aim of five more years of healthy and independent life exacerbate, or reduce, these inequalities?
Inequalities in healthy ageing are driven by socioeconomic and geographic differences amongst population groups. They are compounded by cultural differences that exist amongst people living in the UK. These are not barriers per se but considerations that must be incorporated and addressed during the collaborative design and development of innovations to achieve the aims of the Government Grand Challenge. Successful technology development will reduce rather than exacerbate these inequalities only if all cultural, socioeconomic, and geographic groups play an active role in the iterative design, development, and evaluation of technology-based solutions.
13. What would be the implications of a paradigm shift to people leading healthier lives for longer, and spending less time suffering ill health?
We need to achieve a reduction in health inequalities across different geographic, socioeconomic, and cultural groups within the UK, as well as increased economic output through the establishment of new industrial opportunities that capture the ageing market. A cultural shift wherein older citizens remain net contributors to UK economic growth and GDP for a longer period of their lives is implicit (A Silver Lining for the UK Economy?, Centre for Ageing Better, February 2018).
Many activities and services for active older people are provided by the charitable and third sector. If these organisations are to support healthy ageing and reduce burden on public services spending, the government might additionally consider resourcing third sector organisations or incentivising those associated with improving health span through favourable legislation and/or taxation.
19 September 2019