In healthcare nobody likes to hear ‘no’ — that much is obvious. But in Bermuda it’s also true that nobody likes to say ‘no’. Very few are willing to do it, and it’s costing us a fortune.We, at the Bermuda Health Council, have had intensive discussions about cost-containment with a range of stakeholders in recent months and, while every single person agrees that costs are too high and must be controlled, it’s hard to get consensus on what to cut. Accepting, as we must, that the only way to contain health costs is to use fewer services and/or reduce fees and profits, we are left with few options. Agreeing, as we do, that medically necessary care should be protected, we are left to focus on the areas where there is clear overutilisation — that is, use of healthcare services when they are not medically appropriate or necessary.Such overuse is wasteful because it adds no clinical value and doesn’t improve outcomes. Patients may enjoy the thoroughness and subsequent reassurance that “the tests came back clear” (words we all love to hear). But when those tests weren’t needed in the first place, you have to wonder if they were worth the money. Would the patient have had them if they’d had to pay out of pocket? Would a doctor have ordered them if they’d had to foot the bill themselves? Would a lab have performed them if they were not going to be paid? For each question there are occasions when, “yes” they would have — I certainly know of cases where doctors and labs have done pro bono (unpaid) work. But in most cases the answer is “no”. Overuse is a real problem and in Bermuda we see it especially in diagnostic testing.Up to now, we are probably all on the same page. But I expect at this juncture, if we were sitting in a room, the finger pointing would begin and go something like this (in no particular order):Insurers: “Doctors order all these unnecessary tests and we don’t have any choice but to pay the claims.”Doctors: “Patients want all these tests and if I don’t order them they’ll just go to another doctor.”Patients: “When my health is at stake I don’t want second guesses or delays.”But if we suggest that one of these parties should say “no” (to unnecessary tests), then all Hades breaks loose! Nobody wants to say ‘no’ … because we know how unpopular it is to hear it. But we have few options now, and no single group can say ‘no’ alone. Insurers, doctors and patients will all need to exercise restraint if we’re serious about containing costs. Those high-tech tests will have to be reserved for times when there’s genuine need.Having it all has cost us dearly. We must now choose between changing old ways to bring costs down; or having it all and paying for it.Jennifer Attride-Stirling is CEO of Bermuda Health Council (BHeC)