Iwrite this as an envoi immediately before my departure for a senior health position in Canada. Reflecting on my 35-year career in health care in Australia, I am concerned that, despite all the reform — which has been significant over this period, especially in reducing financial barriers to access — our health care sector still has not tackled fundamental challenges. The health system has been adept in responding to technological change, but our track record in responding to sociological change is poorer, and this gives cause for concern for the future.

Health care use varies with age, with health care use concentrated in the last few years of life — typically over the age of 75 years. In the next decade or so, those aged over 75 years will be “baby boomers”, replacing those who grew up or lived through the Great Depression and World War II. Baby boomers tend to have very different expectations of clinicians and health care facilities, and to have a greater sense of entitlement. Most will also be regular users of the Internet.

So what does this mean? Meekly waiting for care will be a thing of the past. Grateful acceptance of “cattle class” in outpatient departments will also go. “Charity” care by public hospitals officially ended with the introduction of Medicare in 1975, and is not part of the baby boomers’ adult experience. Patronising care, and patients’ acceptance of whatever is on offer, will become a thing of the past. There will be increased expectations of provision of accurate, up-to-date information; frank discussion of choices, attendant risks and likely outcomes; and treatment consistent with contemporary recommendations known to the patient (at worst from the trashy magazines that still adorn waiting rooms, or Internet sites of dubious validity; at best from websites that provide evidence-informed endorsed care paths). These changes are already happening. When things go wrong, there is and will be increasing pursuit of openness about the reasons why.

Changes are also occurring in the workforce: the “team” with the medical team leader is under challenge, with expectations of shared leadership and more egalitarian styles. Nurse practitioners, podiatric surgeons and others are encroaching on the previously sacrosanct medical turf. Unfortunately, medical students still seem to be acculturated into the old paradigm — they emulate what they see their superiors do and, in contrast with other students, grow less team-oriented over their course of study.1

For the past 12 months, I have had dual roles: involved in macro system improvement as a member of the National Health and Hospitals Reform Commission (NHHRC), and leading statewide reform (principally focused on hospital-level change) as chief executive officer of Queensland Health’s Centre for Healthcare Improvement. These roles have involved considering the broad architecture of Australia’s health system and the day-to-day reality of provider-level change.

The interim report of the NHHRC proposed macro levers of change — changed incentives on hospitals through activity-based funding, and on primary health care through steps towards limited enrolment-based care.2 But these macro changes do not, and can not, change the internal workings of hospitals and other health facilities. Levers for that are in the hands of individual managers and staff, and are not amenable to change with the levers in the hands of the NHHRC. Yet it is internal organisational processes that have such a profound impact on the working lives of health sector employees, and in turn affect patients’ experiences of the care received. It is here that the provider-level reforms, such as those initiated by Queensland Health, are so important in setting a context for the interaction between the patient and the clinician (Box).

The changes in Queensland Health were made possible by political commitment to respond to two external reviews of the health system stimulated by the events in Bundaberg.6 The government responded quickly to these inquiries with a significant injection of funds and a reform agenda. Queensland, of course, is not the only state subject to either adverse safety issues or external inquiries.7,8 Unfortunately, the recent Garling Inquiry9 does not appear to have stimulated the same fundamental reform in New South Wales that Queensland embraced.

The macro changes proposed by the NHHRC would lead to improved rationality of Australia’s health care system, and position us better for the technological, demographic and epidemiological challenges that confront us. Organisational changes, such as those being implemented in Queensland, help to create a better environment for the day-to-day workings of the system. But neither will guarantee the fundamental patient-centred reforms needed to respond to the sociological changes described above. Nor will they ensure that the micro environment of care, the interactions between clinicians and patients, between doctors and other health workers, will change.

Of course, no health care system can guarantee perfect care and perfect outcomes for individual patients. It is inevitable that some health professionals will have a “bad hair day” — the result of activities the night before, work pressure, momentary distraction in thinking about issues at home or behaviour of their work colleagues. Even the best intentioned health professional can make a mistake. But it is these micro interactions that determine the patient experience, and tomorrow’s patients will expect more from their encounters and will be less tolerant of practices of the past.

So what is to be done? Recognising the humanity of our patients and coworkers would be a start; as work interactions involve two people who are human, and equal in political and moral terms. So no pedestal, despite the information differential and the “sick role” that clinicians have traditionally expected of those they treat and care for.

Improved leadership is also essential. Tolerance of temper tantrums is becoming a thing of the past. Dealing with aberrant behaviours is not enough. Leaders need to emphasise the importance of good communication between all partners in care, and provide the necessary training and time for this. Training for leaders is a sine qua non, as are systems to support leaders in the challenges they face.

I expect Canada faces similar challenges, and I trust we can all learn from each other in transforming patient care.