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

The Australian health system is a mess.

The current system operates inefficiently between our many levels of government. I believe our politicians are leading a wrongly based debate. They espouse utopian values.

They promise what cannot be delivered, and Australia is supporting professional monopolies that are not good for anyone. Let me explain.

The constitutional power for administering health care in Australia lies with one level of government (the states), while “new money” lies with the Commonwealth. Much of the debate in health is about “blame shifting”, and much of the activity is about “cost shifting” between those two levels of government.

Some states' governments have tried to use area health services to deliver care. These are seen to be more effective because they are closer to the community.

So why is the health system in a mess?

Our system is unsustainable because we promise to our society what cannot be delivered.

Specifically, we promise to deliver, at public expense, all possible care to all people, all the time.

With that promise, admirable as it might be in theory, there is no absurdity in opposition politicians or media drawing attention to the failure of governments to meet that promise.

The reality is different and sobering.

Resources are finite. Resources are not sufficient to provide everything for everyone, and have never been. They will never be able to do that.

We cannot simultaneously provide, at public expense, using the available best contemporary knowledge, the services for procedural care, personal care, protection of the public health, and the prevention of future disease.

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.

We have a monopoly medical system where only those who come from approved courses at universities can access medical benefits. We have restrictions on the entry of overseas-trained people at the same time as we have increasing shortages here. And so on.

Established players claim it is only an interest in “standards” that hold up new players. But they accept and condone, at the same time, the shortages that exist in Australia.

How do we fix it?

This will require a reorientation of the public debate to recognise, and emphasise, that resources in health care are always finite, and that choices always have to be made. Our population must face the fact of increasing ageing, and determine how much public money we should allocate to interventions for people at an advanced age.

But the question is: how might those resource allocation decisions be made? At present, decisions are made. It is just that it is not always obvious how they are made, or who is making them. Some decisions are made by young registrars; some by area accountants. Others are made by ministerial offices, and some are made by admitting officers, especially where responsibility is seen as being to the institution rather than to the community.

There are two sides to any coin. There are costs and benefits to any decision. A decision not to treat “X” might mean a decision to allow treatment of “Y”. But “X” might then die sooner.

Those that argue costs without benefits, or vice versa, are misleading the public.

The best way that decisions seem to have been made so far is to let the public (rather than professionals) decide. This can be done by using what are called “citizen juries”. In this model, juries are empanelled in the usual way, and addressed by advocates for each side of the proposition. The juries then decide. At least in this model, it is clear that a choice has been made, and what costs and benefits will follow.

An American philosopher has invited us to consider withdrawing public subsidy for certain procedures after certain ages. This could be a progressive withdrawal, and would still leave open the option of using disposable income for certain procedures (this is the case now with simple cataract removal in Victoria).

No state Premier and no Prime Minister has told the Australian public the truth, about the possibilities, or the facts.

But something needs to done. For as it stands, our current debate on health is dishonest, misleading and unsustainable.