Asking the tough questions and having crucial conversations: promoting the value and quality of healthcare simultaneously

Globally health systems are in crisis struggling with upward pressure on demands and without concomitant increases in resources. In high-income countries the addition of expensive new technologies is yielding fewer health benefits for every unit of cost and in mid- and lower- income countries the increasing availability of technologies and treatments adds to the upward cost pressures.
Many of these stressors are driven by increases in population numbers and the higher proportion of older persons (Beard et al., 2016). Despite the rhetoric of the importance of prevention, almost all expenditure in healthcare is in the acute care sector and most people spending some time in hospital in their last year of life. In the United Kingdom, four fifths of the money spent on healthcare in people’s last year of life was spent on hospital care (Iacobucci, 2025). This also raises the question of the influence of acute care interventions and the role of prevention in older people.