Bitter pill: let's admit we can't have it all on health

In the past 15 years, national and state election issues have waxed and waned: water, housing affordability and interest rates, national security and terrorism, incumbent hubris, taxation and the economy. All important and deserving of time on centre stage. But one issue bubbles along, always close to front of mind, election after election — health and, particularly, public hospitals.

In this federal election, the health argument has been about dollars and control: more money for hospitals and questions about who should run them, and who has responsibility for their performance.

Of course people worry about the health system. They are confronted almost daily with a horror story. There was the Royal North Shore debacle in Sydney, the Queensland "Dr Death" story, the Royal Perth Hospital management and political meltdown, the Tasmanian Mersey takeover. The media seem to be on a permanent drip of stories that cite familiar concerns: elective surgery waiting lists, hospital/ambulance bypass, surgery cancellations, out-of-pocket expenses, and bed closures due to nurses' industrial action.

Behind the scenes there is no doubt that the system creaks in its bones. Ageing buildings and infrastructure. Drug and clinician costs. Skills and workforce shortages. Escalation of costs and expenses well beyond normal cost of living or expected inflation rates. And public demand that continues to rise and rise.

We understand what drives this demand, what causes the stresses and pressures in a public hospital: an ageing population with complex needs and illnesses, the continual stream of people needing treatment who present at emergency departments, shortages of skilled and well-trained professionals, particularly nurses, to provide care.

We can even look into the future and predict what further pressures will come unless we do something about the pandemic of childhood obesity, address public health issues such as teenager smoking rates, promote healthier lifestyles and choices, deal with the burden of chronic diseases and understand and better treat mental illnesses. But there's a contradiction in all of this. This is also a time when state and federal governments are spending more money on health in absolute terms than they ever have before and larger proportions of their budgets on health than ever before.

And there is some really great stuff going on. The most exciting proposal I have ever been involved with is gathering momentum after years of planning and discussion: a world-class comprehensive cancer centre will rise on the old dental hospital site in Melbourne.

And while all the pressures, concerns and shortcomings I have described are real, consider this: if you are going to have a stroke, a heart attack or a serious car accident, the best place in the world to have it happen must be in Grattan Street, Parkville, outside the the Royal Melbourne Hospital. Or the front door of any of our major public hospitals. Because our care is actually world-best. It is a system in which dedicated, skilled people do amazing jobs to care for the ill and injured. So how can we reconcile and understand two contradictory stories about health? Is it a system under unbearable stress, struggling to cope, where frustrations, shortcomings and failures, even disasters, are bound to happen? Or a story of excellence, even heroism, in dealing with people at their most vulnerable and needy, 24 hours a day?

It's tempting to say glibly that it's both: the best and worst of the same system. But for some time now I have been thinking along a different line, a line that should be up for public discussion. What if it is now impossible for the health system to deliver all that the community expects of it?

If this is true, and I think it is, then we are led to a discussion about our health priorities as a community — or, more bluntly, how we ration a resource that cannot meet all the demands put on it. It would take a brave politician to enter this debate. But it is a debate we will need to have sooner rather than later.