Reform of the kind advocated in this chapter would take time to implement, with many details open to debate and refinement. Moreover, there will be costs and risks in the transition. Accordingly, it is sensible to keep pursuing incremental changes in parallel with exploring the systemic change options. There are also natural limits to structural solutions and to the pace of reform, requiring attention also be given to the ‘people issues’ that will make a difference, including leadership and collaboration, and supporting systems and processes such as better information and transparency and genuine consultation. It is also important to remember that any new system will still have boundaries to manage, and is likely to involve all levels of government, even if some clearer division of responsibilities can be achieved.

However, we should not be satisfied with incremental reforms alone, particularly if they smack of political ad hocracy rather than a clear and coherent longer term strategy that might make systemic reform easier in the future.

The shift towards a truly national health system, with new regional institutions and frameworks as one of its cornerstones, is not predicated on abolition of the federal system nor does it necessarily imply that the State governments disappear. State governments could choose to remain in the area of providing services, and continue to receive Commonwealth funding accordingly, but through the more transparent, accountable and efficient regime provided by the new national system. Equally, however, local government could become a much more major provider of local health services, again taking its funding direct from the Commonwealth through a single purchaser arrangement. Whoever provides the services, the focus of reform needs to be on improving the effectiveness and efficiency of the system when viewed nationally and when viewed from the regional level. The necessary financial resources need to be both centralised in the Commonwealth as the national funder, and then decentralised to regional purchasing authorities in a way consistent with genuine devolution of these important areas of public policy and services.

All of this is both necessary and achievable in the area of health, without constitutional reform, but with appropriate vision and commitment. Whether the lessons of subsidiarity and the limits of connected government, discussed earlier, also make similar reform appropriate to other areas of Australian public policy, is a question worth considering, but which is best left for others to answer.