The folly of merely throwing vast sums of taxpayers money at an unreformed monolithic health service has been amply demonstrated by the failure of the British Labour Government to significantly improve health outcomes despite the squandering of countless extra billions of pounds. That Government, now in its death throes under Gordon Brown, has taken to nagging an increasingly rebellious populous about the dangers of smoking, drinking and eating in a vain effort to improve the nation's health but the nanny state's ever more intrusive regulation into people's personal lives has created only resentment in the ranks.

Medical care is in truth a black hole, the more money it engulfs, the larger it becomes and the more cash it sucks into its ever ravening maw. When the NHS was created in Great Britain, after the Second World War, it was genuinely thought that demand for its services would tend to decline as people grew healthier. In reality as life expectancy has increased with improving living standards and medical technology, then its costs have risen inexorably. Every medical system in the world suffers from the same basic problem, be it a largely statist system in the UK, a largely private system in the USA or a mixture of the two as in many European countries.

When medical care is free at the point of delivery, there is no disincentive, except lengthy queues to dissuade patients from demanding its services, often for the most trivial of reasons. There is nothing your doctor can do about your cold, which is probably not "flu" and your bad back will either cure itself in six weeks or be something you're going to have to live with. The rise of 'alternative medicine', which is in truth nothing but a series of expensive feel good placebos for the scientifically illiterate worried well, has done little to stem the tide although the popularity of such nonsense as homeopathy and other 'complementary therapies' shows that the middle class has plenty of disposable income to spend on health care.

State-funded insurance systems such as Britain's NHS are overwhelmed by demand for trivial and pointless 'treatment' and, in an attempt to keep access open to everyone, resort to default queuing systems to manage demand. Once one has paid one's premium either through taxation or an Australian style insurer, people like to 'get their money's worth' in state and private systems alike. Private insurers try to reduce frivolous demand by insisting on co-payments or deductibles to force patients to share some of the costs but state systems are loathe to pay the political price to be paid for introducing such financial disincentives.

What is needed, therefore, is a system which both offers blanket provision for all regardless of their means but also embodies intelligent disincentives to abuse and overuse by the worried well. One idea, put forward by the Adam Smith Institute among others, is to combine medical insurance with savings accounts.

In the United States such Medical Savings Accounts (MSAs) are becoming increasingly popular,as they reduce the high administrative costs of small claims made on ever more comprehensive traditional tax privileged employer schemes. The insurance cover is reduced to cater for major medical emergencies and the massive savings generated are channelled to the employee's MSA which he is free to spend on any medical procedure he chooses. As the employee keeps the unspent balance he tends not to fritter it away with needless visits to the doctor every time he gets a cold but equally he knows he is covered in the event of a real emergency or chronic condition.
Unfortunately such schemes do not, as a rule, currently gain the tax benefits of other, less efficient schemes but the evidence from American companies shows they reduce demand, guarrentee care in serious cases and cut overall costs by 20%.

Singapore has had a similar system in operation for over twenty years, with citizens paying between 6 and 8% of their income into such 'Medisave' accounts up to a maximum of about $5,000 a year. Once a person's fund grows beyond about $15,000 extra contributions are used to provide for pension savings. The Medisave account pays for certain needs such as psychiatric care, renal dialysis and chemotherapy but is not tapped into to provide for outpatient care, doctors' fees or long-term care. If one person's account runs short of funds, family members can pool their Medisave balances to pay a hospital bill. The Government created the "Medishield" programme of insurance for serious medical problems which 90% of people choose to join, with premiums varying with age. A safety net "Medifund" endowment provides for those too poor to provide for themselves.

South Africa, a country beset by major medical problems not helped by its Government's bizarre attitude to AIDS, has a similar set up. After 1994 all restrictions regarding health plans were abolished, allowing a free for all of different schemes to proliferate. This market testing of rival systems has seen MSAs succeed to the extent to which they now take half the market. Deductible items are varied to encourage patient choice. Medicines for trivial conditions require the patient to pay for a large percentage of them but there are no deductibles for chronic medicines to ensure patients buy and take the medicines which keep their conditions in check and so remove the need for expensive emergency treatment if such conditions are allowed to worsen through neglect.

The concept of MSAs could be as beneficial for state insured systems as they're proving to be in free market ones. Their adoption would see the state fund large scale treatments through taxation, with the cost savings passed on to citizens in their Medical Savings Accounts. Citizens could use these accounts as they wished but ownership of their own money would act as a real disincentive to the frivolous demands which currently clog up Doctor's waiting rooms the length and breadth of the country. Unused funds could be used to improve pension provision, encouraging people to take responsibility for their own preventative care and healthy life styles. The prospect of extra money for staying slim, fit, non smoking and healthy would certainly be more effective than any amount of Government funded nanny state nagging.

Medical Savings Accounts rationally divide the funding of medical care between savings and insurance. Insurance is vital as it protects citizens from the crippling costs of major medical services but the system, by offering a real monetary disincentive to seek treatment for trivial concerns, greatly reduces the medical and, just as importantly, administrative costs incurred at present. In short, as the Adam Smith Institute notes, "MSAs enable the insurers to concentrate on funding the big-ticket items, and give people an incentive to use general services more carefully, while still ensuring that everyone who needs care can get it."

A vision for 2020 should be more than just changing the emphasis on old ideas. The structure of our system has changed little since the 1970's, yet the opportunities for change continue to grow. Some consideration should be given to the phenomenon that our system of silos, not even well interconnected, has been difficult to bring together as individual silos become increasingly specialised, before mitosing into silos which are more specialised still.

Hospitals have become centres of technical excellence, yet decreasing lengths of stay have made them an inappropriate hub for a more holistic or general level of care.

General practice has organised within Divisions and Networks, and many GPs have attempted to adapt the paradigm, but the payment model has not made this easy and the structure of services in the community that might support the more complex care required for chronic disease and multiple morbidity in an ageing population is simply absent. Each GP has to arrange for separate organisations to deliver different aspects of care appropriate to each patient singly and individually if they had the inclination, time and wherewithal to do so.

Neither our lengths of stay nor our community health services support reflect the possibilities we might see in other comparable systems such as the UK, US, Holland and elsewhere in Europe.

It is time for a strategic look at how we can create a unified / integrated structure for teams of health professionals delivering complex care outside hospitals. That is, we developed multi-disciplinary teams of people within hospitals to take care of complex patients. Are the walls of the hospital the key element in the healthfcare paradigm that we use a different structure and paradigm of coordination outside those walls? We now have the capacity to provide most of this care outside hospital walls, using IT and monitoring technology, yet there is no similar organisation of health professionals outside hospitals and GPs, the logical coordinators of care outside hospital have in many cases been de-skilled, but almost universally have been kept outside of any multi-disciplinary care delivery system outside of the hospital.

Moreover, with a renewed emphasis on prevention, integration of new team members - psychologists, people with training in lifestyle management, "behavioural changeists" - shouldn't be created as new silos, but should be integrated so that the messages as to what to do for health or to defer or combat ill-health, can all be integrated. Avoid mixed messages. Aim for simplicity.

Importantly, we also need to invest in the science of finding out what works. We have known about the health risks for decades. we need to invest heavily in the translational research of understanding what works best in practice, because we still don't know especially in chronic disease management. And if we don't know, then all our other knowledge is put to sub-optimal use.

Unfortunately, the current guardians of our research are rooted in another paradigm and translational research funding needs to be placed in other hands with different expertise, or at least partitioned and magnified. Dr Carolyn Clancy, Director of the US Agency for Healthcare Research and Quality has been quoted as suggesting about 1% of research funding has been going into determining how to apply the knowledge we have gained with the other 99%. It may be slightly better here, but not that much.

So ... new structures, new training, multi-disciplinary GP-inclusive, outside hospital teams with access to technical and equipment support, new health professionals to make prevention and disease management inclusive, and transaltional research funding, should all be essential elements of a vision for 2009, let alone 2020. 2009 is a great time to start to move holistic care and less intensive, less expensive care out of the hospitals and back to the primary carers - teams of primary carers.

Good luck.

Stan Goldstein

I'm told I should have been simple and practical.

To that end, some ideas:

Quarantine a significant amount of funding for research - NHMRC - even if for a short period such as three years, for transaltional research - working out whether you can change the health of the population by putting in different models of intervention, seeing whether "guidelines" can be implemented practically, etc. That is no additional cost to government, but will cause those who have expectations of status quo in research funding some alarm. 20% (even 10%) of current research allocation would be appropriate.

Seed fund the fledgeling Australian Lifestyle Management Assocation and Australian Disease Management Associations for three years. To move to a more prevention oriented paradigm you will need new champions of a preventive approach. That is not only public health, but also a new approach to learning how we can help individuals modify their lifestyles to reduce risk, and help systems to achieve best results in health outcomes where risk is already established. Seed the champions who can carry the baton. If you also seed the research - the evidence they need to be able to argue the case for prevention and better management, then you will have someone to argue for change ... for the better. Total cost: at your discretion but probably less than $2m over 3 years.

Trial a comprehensive complex ambulatory care organisation able to serve both public and private sectors (details available if you ask). Having options for complex care outside hospitals, including personnel, equipment and clinical pathways, can keep patients under GP care in the community or even in aged care facilities when hospital might be the only other choice. Test it: it might save you money. It certainly has the potential to do so (story of how a doctor had to fight to keep his elderly father out of hospital against the will of the professionals on the inside is available on demand too!).

If you do that, we'll all be busy making a better more responsive healthcare network for the next few years.

Outcomes? You've already got everyone trying to work on that one through the NHHRC but just thought I'd mention it for completeness.

Thanks again for listening.

One huge possibility for the Australian people is to promote a healthy, active society. One which shows awareness in every stream of thinking and certainly one within the barriers of social estimates.

By 2020 I strongly urge the federal govt. to work alongside the states to promote healthy living, by introducing a rewards system for people when buying healthy fresh produce from our supermarkets. For any particular combination of healthy fresh produce purchased from participating supermarkets... "families" should be rewarded on their grocery bill or something similar like a rewards point card. It that simple!

And this could certainly help tackle our national epidemic of childhood obesity, and also work as a guideline and a framework for families who seem to struggle with the message of healthy eating, not just with their children, but with themselves also.

I think its spells victory for a nation who spend millions of dollars on advertising campaigns without success. And our future depends on the "Awareness" factor when most people look for cure & prevention. No, lets reward an unaware society by introducing these incentives and promote a stronger, more flexible itinerary for families abroad, who may find it difficult to accept the current era in which most families struggle.

That's a real 2020 vision and I hope we can approach this "Health & awareness" issue by capitalizing on the fundamentals of peoples mindsets, and allow people to benefit from active participation in their own health & prosperity.

The only cure & prevention for a sustainable freedom is "HEALTH & AWARENESS"... So lets boost the itinerary and help one another participate. Thank you!

Damien McCracken (28yrs)

Ipswich, QLD