Healthcare reform: possible ways forward.

THERE IS LITTLE DISAGREEMENT about the directions public health reform should take — greater emphasis on primary and preventive care, workforce reform, community participation, improved governance and better application of information technology. It is clear that there are gaps and duplication in clinical services that reflect outdated population patterns and jealously guarded clinical territories. There is concern about the health disadvantage of certain groups, and particularly Aboriginal and Torres Strait Islander people. In quality of life measured by life expectancy , Australia ranks number two in the world, but in healthcare equality we rank number 17. 1 If all Australians had the same health experience as Aborigines, we would rank number 140 in the world, alongside Bangladesh. These issues are common to many advanced healthcare systems. This is confirmed by almost any healthcare enquiry or commission. One doesn't have to be a rocket scientist to know where we need to head. But there is considerable disappointment and disillusion-ment about the ability of the leaders of our health systems to lead and manage the change. And the public is right about the failure of health leadership — political, clinical and managerial. In the two inquiries I headed in New South Wales 2 and South Australia, 3 the cynicism I encountered was abundant and depressing. I was continually told that " your inquiry may be well and good, but nothing will really happen ". I understand their cynicism. It is part of a larger issue of alienation, which the community feels towards all our major institutions — parliament, political parties, the media, trade unions, companies, and churches. 4 We so often feel that they are not honest and open with us, and that they try to manage and manipulate information to protect their own interests. Major institutions have lost touch with their natural constituencies. It is true in healthcare. I would like to identify briefly some of the major underlying problems and then suggest some possible ways forward. My comments are very much influenced by observing, at close hand, the NSW and South Australian health systems and the way they relate and react to Commonwealth health funding. ■ There is clearly a failure of the Commonwealth and states to cooperate in the funding and delivery of healthcare services, with resulting inefficiencies, buck-passing, cost-shifting and poor integration. It was made clear to me in NSW and SA that the public wants change here, …