Dispense with the misguided utopian myths about our health-care system.

Choices between possible uses of resources will have to be made in the future, as they have been made in the past, as they are being made at the moment.

Failure to recognise what is above, or to say it clearly to the public, makes it inevitable that there will be failures within the system. But they are not so much failures as the inevitable result of flawed debate.

The arguments today about health care are about who gets publicly-subsidised help; about who misses out; about how long people have to wait, and so on. But it is the politically powerful and the politically savvy who usually win these arguments.

The fact that there are significant, and growing, regional and class differences is just becoming clear.

Idealists may wish things were different but must consider the realities. Money for medical services and hospitals is allocated, both federally and in the states, as part of the budget process.

This statement needs to be modified only to the extent that Medicare payments and pharmaceutical benefits, are “entitlements”, and the quantum is determined at the end of the accounting period on the basis of claims made. An eloquent minister, at either level, could expect to win an extra amount in budget discussions.

The amount, however, is likely to be relatively small and finite. After all, budget discussions occur in an environment where the size of the cake is known. A bigger slice of that cake for one supplicant means smaller slices for one or more others.

As a result, that same minister might not get a similar increase in future years, and, in any case, when that resource is used up, choices still have to be made.

There are always shortages. There are always things that could be done but are not done.

In the absence of an enlightened or educated intervention by the public, the choices between possible interventions are made “off stage” by others, often providers or administrators. But their values are never examined; their reasons and rationale are never tested.

And now, a word about monopolies.

In order to stop “fly by night” operators and training institutions, governments have instituted systems of licensing for most people in the personal-care area. But they have often passed the administration of those systems back to the interested professions, which then act as a “choke” for the entry of new players.