After decades of short term funding, reactive policy making and short planning cycles we should be delighted to finally see genuine moves to longer term thinking with things like the establishment of the Foresight projects in England and the Well-being of Future Generations Act in Wales. And these do seem to have helped to stimulate policy makers and public sector organisations to at least start to think and plan for the longer term. For example in Wales there is a requirement for Public Service Boards to develop and published Well-being plans with supporting assessments that include evidence of long-term thinking. This has been supported by the publication of a tool by the Public Health Observatory in Wales that offers some insights on potential trends for 5 key health & lifestyle indicators over the next 10 years based on present and past data. And whilst looking 10 years ahead is a move forward for public sector planners is this really ‘long-term thinking’ and just how useful is trend data? Given the major global and domestic fiscal and political changes, there are likely to be significant confounding factors not accounted for in the present trend analyses that I believe will seriously impact on current projections particularly when considered in the genuinely long-term including;

  • The emerging, though not yet acknowledged, increasing outward migration of disillusioned working age adults, predominantly from the present 10-30yrs of age, middle income group leaving higher education with an increasing burden of debt initiated by student loans and low and diminishing job prospects that are poorly aligned to their qualifications, aspirations and expectations. (Eisenhammer S, 2012; The Economist, 2014))
  • An increasing outward migration of UK based foreign workers forced out by economic and social uncertainty in an increasingly hostile policy environment; couple with a dramatic reduction in inward migration resulting from xenophobic immigration policies. (ONS, 2017)
  • The increasing number of present 10-30yrs age lower and middle income group (many, though not all, burdened by student debt) entering an insecure and low paid employment market with frequent episodes of unemployment, a punitive benefits system, no access to the housing market and unable to contribute to a pension scheme.
  • An exponentially continuing upward trend in mental health problems beginning at an earlier age (under 10 yrs) resulting from social pressures fuelled in part by emerging social technology and in part by increasing expectations; coupled with increasing numbers of adults and older adults exposed to increasing work and financial pressures. (Campbell D & Marsh S, 2016)
  • The unaccounted impacts of extending the retirement age across the population irrespective of the nature of the work, leading to workforce imbalances as older workers are forced into premature retirement through sickness (Principally as a result of musculo-skeletal disease, injuries, diabetes, CVD and dementia) leading to increased pressures on those trying to pick up the slack left by the increasing sickness absences. (Staubli S & Zweimuller J, 2013).
  • The increasing reliance on a rapidly diminishing resource of young and working age adult informal carers for the increasingly older and frailer population with increasing care needs.(Age UK, 2017)
  • The continuing demographic shift in alcohol and substance misuse from younger to older generations. (Conelly A et. al; 2017)
  • The continuing personal and social financial impacts of gambling (particularly online) on poverty, homelessness etc. particularly among younger and working age adults. (NHS Digital, 2017)

On a more positive note there are likely to be some improvements in some of the ‘lifestyle’ related chronic diseases as social norms change: This could include:

  • Slowly reducing prevalence of obesity (There is some evidence of overall rates of childhood obesity levelling off, and in some cases falling, in some of the worst affected countries. E.g. USA, England) although there will continue to be a socio-economic inequality. (Sahota B, 2015)
  • Tobacco use continuing its downward trend as ‘vaping’ becomes more popular. (Press Association, 2017)

If these less concrete predictions were to happen the health impacts would of course be significant and, more alarmingly, further compound inequalities with an ever increasing health and social divide between the ‘haves’ and ‘have not’s’. But perhaps of even more concern will be the increasing generational inequalities as present and emerging social and political trends isolate the ‘noughties’ generation with inevitable trickle down impacts on our children & young people, the very generation we so vociferously claim to be our primary priority? We have been aware for some time of the demographic time bomb of an ageing population and the increasing demands it is already placing on increasingly stretched health resources. However I would suggest we have not yet woken up to the more frightening prospect of this ‘betrayed’ generation whose capacity to contribute to their own health needs has been massively compromised, never mind the expectation that they will be able to contribute to supporting the health needs of their parents! The political and public health prioritisation on maternal and child health that we are witnessing is hard to challenge but the health and well-being of future generations cannot operate in isolation and is wholly dependent on addressing the needs of our present generations’ right across the life course. It is ludicrous to put all our eggs into one ‘early years’ basket and ignore the needs of the rest (the bulk) of our population because to do so will result in a downward spiral that will negate any investments that we are presently making in our children and young people. Why bother working upstream if you’re building a dam further down? All you end up with is a flood and tens of thousands of displaced people.

These demographic considerations don’t of course take account of other possible major confounders such as war, austerity as the new ‘norm’, global warming, Brexit, antibiotic resistance, food scarcity, increasing automation etc. but they do highlight the limitations of horizon scanning that is reliant on statistical trend data.

There is a school of thought that we are now entering a third revolution in health following the shift from communicable disease to non-communicable disease in the 20th Century and now from non-communicable disease we are in an ‘epidemiological transition’ to the 3rd era of ‘positive health’ where health is recognised as a “resource for everyday life” (Breslow L, 2004). In the same way as we had to adapt our thinking to accommodate the notion of non-communicable disease, including the causes, effects and measurement, we must now re-orientate our thinking to the notion of ‘health as a resource’. If we do subscribe to that approach then we must also recognise its place as it competes in the modern world with other resources, both personal and societal. In that context it is not surprising that the ‘burden of disease’ that we have recognised over the last century is changing again to reflect the social and ecological changes that are leading to a move away from the ‘lifestyle’ paradigm that has dominated recent decades to the ‘personal resource’ model where the focus will be on mental illness (anxiety, depression, OCD, etc.) and age-related diseases (dementia, osteo-arthritis, sensory impairments, particular cancers etc.) and where the wider social determinants including economic, political, environmental and commercial play an increasingly important role.

There is undoubtedly a place for trend data; it is based on known quantifiable facts and provides a valuable and visually compelling picture of where we have been and where we could be going, if nothing were to change. It doesn’t, however, represent a true picture because of course things do change. But the things that change are often not quantifiable or predictable over the long term, which is why methods such as Foresight that provides different scenarios that account for potential changes in the macro economic and political world can add that critically important dimension to forward planning that a simple reliance on trend data never will.


Age UK (2017), Briefing: Health and Care of Older People in England 2017, Feb 2017,

Breslow L (2004), The Third Revolution in Health, Annual Review of Public Health, Vol. 25:- (Volume publication date 21 April 2004)

Campbell D & Marsh S (2016), Quarter of a million children receiving mental health care in England,the Guardian, Monday 3 Oct 2016;

Conolly A, Fuller E, Jones E, Maplethorpe N, Sondaal A, Wardle H (2017), Gambling behaviour in Great Britain in 2015 Evidence from England, Scotland and Wales, Pub: NatCen Social Research.

Eisenhammer S (2012), Britain faces “brain drain” as jobs dry up, Reuters, November  12, 2012,

NHS Digital (2017), Statistics on Alcohol, England, 2017 [NS],

Office for National Statistics (2017), Migration Statistics Quarterly Report: August 2017,

Press Association (2017), Smoking rate in UK falls to second-lowest in Europe, The Guardian, 15thJune 2017,

Staubli S & Zweimuller J (2013), Does Raising the Early Retirement Age Increase Employment of Older Workers?, J Public Econ  doi:  10.1016/j.jpubeco.2013.09.003

Sahota B (2015), Recent UK trends in childhood obesity, British J Obesity,

The Economist (2014), “And don’t come back”, The Economist,

Welsh Government (2015),  Well-being of Future Generations (Wales) Act 2015 – The Essentials, Pub: Welsh Government, May 2015.


Malcolm Ward FFPH,MPH,PG Dip.