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Thanks very much for replying Sheena I really appreciate it. It does make sense, although I think there may be more to explore, both in terms of what the system understands about demand (not a great deal it seems from my studies) and around end of life and what we do with/for people.

Its an interesting point you make about the denial of treatment. I also see what you mean about age and dying going together but I think there is a more nuanced aspect to this. What I see is that despite the evidence that exists that talking to people about their options leads them to make less resource intensive decisions we don't do it. Aetna, a medical insurance group, ran a two year program where patients were allowed to receive hospice treatment without forgoing other treatments. They found that visits to the emergency room dropped by almost half and the use of hospitals and ICUs dropped by more than two thirds, compared to the control group.

In a smaller but broader study, they found the use of ICU reduced by over 85%. The reasons for these findings? People were involved in decisions about their life and, rather than choose the heroic, life saving interventions - the greater consumption options - they chose to die with dignity and with the ability to say "goodbye" or "I love you", a choice foregone if unconscious and intubated on an ICU.

My, as yet unpublished, studies show similar reductions in consumption of other services (nursing/residential homes etc) by taking the time to understand people in the context of how they live their life.

So right now my studies are leading me to conclude that age is not the problem that it is described as (e.g. time bomb etc). Studies like Wong and others are leaning me further in that direction too. Admittedly I am no expert in epidemiology or the methodology they used so remain open minded.

Not sure if this adds anything to the particular debate about funding formula but certainly what I am seeing is that costs are being driven by a system response that makes people live the life the system has decided rather than live the life they want, the latter being significantly more affordable ironically.

Not sure if links work here but if they do and it helps you can read a bit more about where I am coming from here http://vanguardinhealth.blogspot.co.uk/2012/02/million-dollar-murray.html

Thanks again. Its an interesting debate.