Starting point is that there is a wide consensus on what is a good health care system:

1. The Future of Health in Europe13 May 2011The European Institute UCLThe Finnish Institute in LondonUCL Grand Challenges A Preliminary Summing Up (or ‘After the Lord Mayor’s Show’)Albert WealeSchool of Public PolicyUniversity College London

2. Starting point is that there is a wide consensus on what is a good health care system: • High quality • Comprehensive • No financial barriers to access • But, the problem is how to achieve these values in practice when there is the underlying dilemma of cost-control and ensuring price-worthy health care.

3. A note on the definition of the problem • The growth of health care expenditure over income is similar to the growth of expenditure for luxury items (eating out, exotic holidays). So why the problem about health care? • Crucial issue is that the costs fall on the public. • There are three main groups of actors: patients, providers and the public. • So the problem is not cost per se, but the sense that the underlying social contract (between patients, providers and the public finance) is coming under strain (compare Huebel).

4. What are the means for producing price-worthy healthcare? • Reduce demands on the system, e.g., by prevention. • Get provider efficiency into the system. • Restrict public finance for high cost therapies. • Persuade people that rising costs are value for money. • Reduce provider incomes.

5. 1. Reduce demands on the system • Since diseases have a social origin, better social organisation leads to better health (Marmot). • Political will is a question of the will of a particular coalition of actors, and there is a large question about how inclusive that coalition is. • Marmot showed that the issue was inequality, not just deprivation.

6. 2. Increase productivity in the system • Greater use of risk-stratification technologies (Tooke). • Prospects for regenerative medicine (Coffey) • Use of ICT either for EHRs or consultations (Murray, Tiik) • But we start from where with diverse populations to be served (Okolo) and with political commitments to forms of political organisation (Erhola). • And the extent to which any particular technology will reduce costs is an empirical question. In some case the technology means that people will not have to live with diseases they used to have to put up with.

7. 3. Restrict public financial support for high cost therapies. • Exclusions of coverage will always apply. The trick is to make them efficient and fair: ‘Rationing in a socially responsible way.’ (Tooke) • NICE is at the forefront of this problem. (Littlejohns) • Public consultation is central to this. But our technology assessment on the technology of public consultation lags behind our assessment of health care technology. • Value-based pricing. Can we get this right? (See background paper by Jo Wolff.)

8. 4. Persuade people to spend more • Clearly people are willing to spend on their own health (Morris), so the problem is persuading people to make their contribution to a public system. • Unless that public system is maintained, then there will be financial barriers to access for the poor. • In a global perspective most countries do not have a functioning system of public cost-sharing.

9. 5. Reduce provider incomes • Since by definition all expenditure must equal income, one way of reducing costs is to drive down producer incomes. • Empirical issues are complicated here, but we cannot assume that more competition is cost-reducing though in large parts of the economy this is true.

10. Final Thought ‘The life you save may be your own.’ Thomas Schelling