To the Editor: Duckett rightly points out that community knowledge and expectations of the delivery of medical services have increased in recent years, and that the “baby boomers” of today will not accept the hospitals of yesteryear.1 He claims that the Australian health system has responded to technological change, but not to sociological change.

Although the introduction of new medical technologies — a process largely driven by clinicians — has helped ensure that Australians still have access to quality health care, the same claim can not be made for the other kinds of technologies necessary to support delivery and review of good-quality care; notably, health information technology lags lamentably behind other sectors. In addition, we have not been “adept in responding to technological change”, because we have not figured out how we are to pay for it.

The sociological changes that Duckett is concerned with are well recognised by many working in the public health sector. He states that macro- and provider-level reforms set the context for the interaction between the patient and clinician. He seems inclined to view this interaction as the final frontier — resistant to change and responsible for what he characterises as an ongoing lack of responsiveness in hospitals and health facilities.

However, his outdated and stereotypical characterisation of doctors working in the public health sector must call into question his knowledge of what actually goes on in modern health care settings, in addition to pointing to a tendency to underestimate the difficulties of working in these austere and pressured environments.

The conversation that privileged baby boomers actually need to have is one that forms part of a public debate about how much health care costs and how we should be thinking about rationing its delivery, or else paying more for it, as Queensland Health has perhaps finally learned.

It is disappointing that, despite Duckett’s long years of experience in the public health sector, he fails to address the real implications of the changes, both technological and sociological, to which he alludes in his opening paragraph — how exactly are we going to manage the ever-increasing demand for increasingly expensive treatments by an ageing population?

To the Editor: The next challenge for medicine in Australia, in Duckett’s opinion, will be the need to provide for the “very different expectations . . . and a greater sense of entitlement” of baby boomers, as they reach old age and have more need for health services, in and out of hospital.1

They will not meekly wait for care — but how will waiting lists for appointments and elective surgery be abolished? They will not accept “cattle class” in outpatient departments — but who will pay for the replacement of wooden benches with easy chairs? They will not accept whatever is on offer — but who will provide what is not on offer at a time of need? They will expect frank discussion of choices, risks and outcomes — but which cardiac surgeon or registrar will have the time to go into the 40 different possible complications of coronary artery bypass, an operation with usually excellent results? And if nurse practitioners or podiatrists become leaders of the medical team, will they be professionally and legally responsible when outcomes are unsatisfactory or disastrous?

People with visions of the ideal medical service should keep in mind a basic principle, expressed by Enoch Powell 42 years ago.2 Even in prosperous times, limited resources (trained staff, facilities and money) will never meet unlimited demands. Duckett’s baby boomers may have expectations, but they must be measured against reality. With the unceasing growth of knowledge, technology and pharmacology, medicine is not about to become cheaper.

In reply: Notwithstanding the differences in tone, Cleland and Meyers make the same substantive point: that a challenge I ignored in my short piece was the costs of meeting the different expectations of baby boomers. Regardless of the changed expectations I discussed in my article, health costs over the next few decades are predicted to increase from just over 9% of gross domestic product to over 12%.1 Economists recognise that societies appear willing to devote more spending to health care as they get wealthier, perhaps to avoid confronting the difficult choices involved in some rationing decisions.2

But should we immediately jump to the conclusion that more rationing is inevitable? What other choices are there? First, we — policymakers and clinicians alike — need to address the waste and inefficiency inherent in the current system;3 and, second, change the health system so that it is better suited to respond to changing needs4 and potentially “bend the trend” of health cost projections.

Third, we need to recognise that rationing — or, to use a less emotive term, priority setting — is already part of our health system. Australia leads the world in terms of formal processes before listing new drugs on the Pharmaceutical Benefits Scheme or items on the Medicare Benefits Schedule, but here too, improvements are needed.

Clinicians are already involved in rationing choices, but different clinicians appear to have different thresholds of when (and what) treatment should be recommended. These differences may be cultural,5 and addressing these unexplained variations in practice patterns remains a policy work in progress.

Thus, we in the health system have a lot of work to do in putting our house in order so that any rationing debate can occur knowing that alternative strategies have already been pursued.