Ummm ... now, about the crisis in the Australian healthcare system ...

For years I have repeated: 'There is no Australian healthcare crisis. Australia enjoys very good health by international standards. Australia has a very good health system. Australians like Medicare. Medicare has some problems and they need fixing. But ... THERE IS NO CRISIS!'

Recently though, I have thought again. There is a crisis looming. But it isn't dollars or waiting lists or nurses or EDs or hospital beds or GPs, or any other recurrent headline-grabber. It isn't even medical indemnity, although I concede that, unlike the others, this is a new problem. And it isn't the continuing appalling state of indigenous health (how can it be 'a crisis'? it's been bad for decades and is improving slowly) or the growing epidemic of obesity -- or any of the other health, rather than healthcare, problems that beset Australians.

No, the real crisis is the totally inadequate attention being given to the development of long-term goals and coordinated strategies for Australia's health system.

The division of powers between the Commonwealth and State governments has created problems since Federation, not only in healthcare. But it seems that we are moving into a new phase where cooperation, willing or unwilling, between the jurisdictions is being replaced with health ministers preferring to blame each other publicly for the symptoms of poor planning and coordination: ('he can't run his state's hospitals efficiently'; 'she won't improve bulk-billing rates'), rather than work together to create a sustainable system. The result is an increasingly dysfunctional health system that will eventually fail to deliver good health and good healthcare for all Australians.

So why is this so and how might we proceed?

Having nine jurisdictions with different parties in power and different electoral cycles is a major impediment to good planning and coordinated service delivery. This will not change, however, so we must continue to live with it.

The split responsibilities, grounded in the Constitution, are another hurdle. It has long been mooted, and it will involve major upheavals, but we must move to a simpler healthcare system. The Commonwealth controls the money, so maybe they should be responsible for all the services.

The current Commonwealth Government is deliberately dismantling Medicare piece by piece, no matter what its rhetoric. It is misrepresenting the aims and principles of Medicare. It is shamelessly wasting over $2 billion a year on the totally ineffective private health insurance rebate. It is redefining bulk-billing to destroy its purpose. It is entering into trade agreements with the USA and other countries (through GATS) that seriously threaten the integrity, efficiency and excellent cost-control record of Australia's healthcare system. Why a government would want to destroy a highly productive, cost-effective, well-liked, internationally admired system to create a more fragmented, more costly one (for individuals and for Australia) is totally beyond me. Anyone who cares about health, equity, universality, and service availability on the basis of need not ability to pay must oppose this underhand deconstruction of Australia's healthcare system.

Forces whose primary interest is neither improved health nor improved healthcare are driving many of the current developments in Australia's healthcare system: reduced direct taxation, international trade agreements, doctors' salaries, corporate profits, cost-shifting, political points scoring, professional rivalries, to name a few. This is compounded by an all-too-frequent focus in parliaments, policy and the press on inputs ('we're spending more on health than the previous government'; 'we need more hospital beds'), and outputs (number of bed days per year, length of waiting lists), rather than service quality, value for money and health outcomes.

Health departments across Australia have plans for every conceivable service, population group, illness and risk factor. We also have the Australian Healthcare Agreement between the Commonwealth and State Governments. But these are like railway carriages with no engine and no track. We need a national plan, agreed by all jurisdictions, that clearly specifies the overall goals of the health system, its underlying values, and the broad strategies to achieve it.

As President of the Public Health Association, I must emphasise that such a plan should include more emphasis and more funding for health promotion. This is evidence-based and cost-saving; a wise investment. Also, the national plan must be developed in consultation with an informed community (who know what they need and what they are prepared to pay), and service providers (who know what's practical and what will be soon).

Such a plan will not be developed overnight and it will involve many compromises. But the real crisis is looming, and those who should be taking it seriously are ignoring it. The alternative, continuing to undermine a good but not perfect system, will have disastrous consequences for all Australians.