1. The Challenge of Getting Value in Health Care. Charles Normand, Edward Kennedy Professor of Health Policy and Management Trinity College Dublin

2. Three Key Issues and Three Perspectives Providing the most cost-effective portfolio of services Providing services efficiently Paying the right price for services and inputs. What is needed to improve things What is happening in Ireland What next steps.

3. Background 1 Incremental and largely haphazard development of health system and infrastructure More systematic efforts in last 20-30 years In 2 o and 3 o services More recent and more tentative steps to strengthen 1 o care Large fluctuations in government funding (both too much more and cuts too large).

4. Background 2 Large role of out of pocket payments and supplementary insurance (with important effects on incentives and entitlements). Private sector significantly subsidised.

5. Providing the most cost- effective services 1 Evaluate existing and new services Currently limited evaluation of drugs and technology Plans to widen HTA Almost no explicit rationing based on evidence Some focus on improving services in areas where interventions are known to be cost-effective (eg cervical screening).

6. Providing the most cost- effective services 2 Effects of incentives on point of contact services tends to discourage cost effect use Role of out of pocket payments and private insurance makes it harder to ensure best use of government funding Schemes such as NTPF can improve the short term situation but tend to distort priorities in the long run.

7. Providing the most cost- effective services 3 Need for shift to more explicit rationing Need to develop stronger evidence based on some primary research and some systematic use of secondary evidence Need for planning to be more evidence based.

8. Providing services efficiently 1 Developing a more suitable infrastructure Buildings Equipment Human capital The right incentives The way we pay providers (organisations and people).

9. Providing services efficiently 2 Poor hospital stock Odd approach to equipment Poor 10 care infrastructure Inappropriate skill mix.

10. Providing services efficiently 3 Need for Programme of capital investment Better systems to manage equipment renewal etc Better HR planning needed Changes needed in the way we pay and reimburse hospitals, PHC, doctors Probably too little spent on management.

11. Prices of Health Care Inputs 1 There is never a free market in the prices and charges for professional services Health care technology never sold in free market We need to recognise the issues around protection of professionals, protection of the public and pay and conditions.

12. Prices of Health Care Inputs 2 To what extent is there scope for Lower prices for drugs and devices Skilled professional staff Other staff Capital assets Without harming other policy objectives?.

13. Final thoughts We have had health strategies but not adequate levers to move towards objectives For various reasons we have been slow to make changes that would improve efficiency and cost-effectiveness of programmes Although there are long term problems that need long term solutions, we can do a lot by changing systems and incentive within current structures.

14. The End Thank you for your attention