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 It is clear that there are gaps and duplication in clinical services that reflect outdated population patterns and jealously guarded clinical territories.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 disillusionment 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 Wales2 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.

In attempting to tackle these issues, the plea invariably is “more money please”. More money is clearly necessary in key areas, but more investment in doing the same things the same way will only delay reform. It encourages just the attitude that is at the centre of our problems — that resources are unlimited and that choices do not have to be made. It will be the same old treadmill. Governments and taxpayers rightly insist on value for money. Reform will not be successful unless we can persuade treasuries that the money will be better spent in the future. In achieving that, I believe some or all of the following elements need to be in place.

I am sure that a joint service would deliver better quality and efficiency of care, even if no additional funds were provided. So let us put that joint Commonwealth/state health commission on the agenda, put the case as compellingly as we can, and hopefully within 3 to 5 years we would have started to break the wasteful impasse and buck-passing of the present divided jurisdictional system.

The roles of ministers, health executives, boards and health institutions, particularly in the states and territories, must be clearly defined and accountabilities established. The micromanagement of healthcare systems by ministers and their private offices must be stopped. I have heard and seen at first hand endless cases of private ministerial staff members who suppose that, as the minister’s alter egos, they can hector quite senior clinical and non-clinical staff. Some members of ministerial staff even think it is appropriate to try to micromanage external and independent committees of review. This is not a new problem, nor is it restricted to one government. It is a very serious problem. Certainly, ministers and their offices need to manage short-term crises and they need to get on top of some of the detail, and there is a lot of detail in healthcare, but so often they allow themselves to be submerged by the detail, lose their way and allow the nightly TV news to set the agenda. So, ministers spend disproportionate amounts of time putting out brush fires. Media management and micromanagement by ministers and their offices go hand in glove.

This preoccupation with daily crises and micromanagement has many unfortunate consequences — long-term issues, such as the reform agenda we are discussing at this summit, are put on the back-burner. Senior executive officers are confused and reluctant to make decisions. They become gun-shy. They manage upwards to the minister. The minister becomes the client, and not the public. Disproportionate resources and energy are spent serving the minister, and particularly his or her staff. The central department also becomes too close to the political agenda of the minister, with the emphasis on news management. In my experience, private staff of ministers are petrified at the prospect of robust discussion and debate.

This issue must be addressed, or confusion and frustration at senior levels will continue to paralyse the system. Only ministers can lead this change and forgo their micromanagement. It is not only in the interests of a well functioning system for them to do this, but it would seem clearly in their own interests to break out of the daily political cycle of calls for more beds and complaints about ambulance bypasses. The healthcare system would greatly benefit if they would use their political credit and influence to win the debate and change the system — to achieve, for example, better primary care, improved mental healthcare and putting us on track to remedying the most disastrous problem of all, poor Aboriginal health.

In speaking of micromanagement, I know I am treading on toes, but if I could paraphrase the words of Confucius when asked “how to serve the minister”, the sage replied “tell him the truth, even if it offends him”.

Great care is also necessary in choosing boards of governance, for getting the governance structure right will not be sufficient if ministers appoint political or personal extensions of themselves. Similarly, board members must carefully and determinedly assert their duties to ensure good governance, and not knuckle under to short-term pressures. Governance boards are not the same as advisory committees. They must be structured and appointed with full regard to the overarching responsibilities which governance boards have — financial, ethical and legal probity, adherence to occupational health and safety standards, high standards of professional conduct and competence and efficiency.

There must be major and successful communication campaigns to establish what are the clear priorities in healthcare spending. Expenditure on healthcare in Australia has increased from about 6% to 9% of GDP (gross domestic product) over the last 40 years. While healthcare demands are almost unlimited, resources are finite. The health budgets of Commonwealth and state governments are clearly not sustainable into the future.

I have seen numerous surveys of community priorities in health. They all tell very largely the same story. Whilst the community appreciates the important role of hospitals, they see mental health as today’s top priority, followed by the health of children (particularly children subject to violence), and Aboriginal health. The community speaks very clearly and consistently on these issues, but they do not shape the priorities in spending. Insiders make the decisions.

Ministers give lip service to community participation, but many quite seriously believe that they represent the community, so do not see the need for another level of community participation. Unless the Commonwealth and state governments involve the community in setting priorities in health spending, we will not make real progress in systemic reform. We called our South Australian report “Better choices, better health”.3 Choices cannot be avoided. Unless the community is locked in through appropriate structures and processes, health reform will not happen. The public must be connected.

We are rightly proud in Australia of the workforce renewal that has helped transform the Australian economy. But that workforce renewal has not really touched the professions, and particularly the healthcare sector, where jobs need substantial redesigning and work processes must be significantly re-engineered. Over a period, this could deliver major productivity gains and enhanced job satisfaction, particularly for nurses. New people with resolution, new ideas and new attitudes are essential if workforce renewal is to occur.

Finally, I guess all this comes down to leadership — political, clinical and managerial. My recent experience in SA is that the public wants to be engaged, and responds very positively to a well argued case for change. That case requires leaders prepared to take risks.