It would also be imprudent to suggest that the gains from changes in system structures and function changes can be achieved without continuing investment in the health system. There are several reasons for this, the principal one being that healthcare is expensive. We need only look at the increased frequency and volume of MRIs in recent years as a classic illustration of technological advances in healthcare There are also an ageing population and higher levels of public knowledge and expectations, combined with pay and non-pay inflation, which make it expensive just to stand still. From a cost viewpoint, there is a cruel paradox in the fact that the more successful the outcome, the more expensive it gets. When we appoint an oncologist, the service will improve and the treatments increase, as will the expenditure. That is what is happening in many of our acute hospitals.