Conventional political wisdom states that national elections are determined by one central issue — the economy. In Australia in 2010, it is distinctly possible that the state of our national health system will emerge as an equally important concern.

In his Australia Day statements, the Prime Minister Kevin Rudd has confirmed that health is still the No.1 domestic issue. Interestingly, he has moved the focus of discussion from the quality of health services to economic productivity. The strong hand of Treasury, not Health, in framing the health-reform debate is now clear.

At this stage, neither side of Federal politics is responsive to the real needs of those Australians who rely on the health-care system to meet their essential needs. In health, the most important date in 2009 was the December 7. After two years of expert committees, consultation and endless dialogue, the PM committed to release his government’s plan to reinvigorate our national system. Sadly, this seminal meeting came and went with nothing more than the fatuous statement “COAG agreed that national health reform would be a central priority for 2010”.

In 2007, Rudd promised to end the blame game and, if necessary, take over the state-based public hospital system. After the 2007 election, he committed to detail his health-reform agenda by mid-2009. Now he has described the problem as one related to the adverse impact of the costs of health and aged-care services on the national economy. Sadly, as we enter 2010 we are still none the wiser about the size or scope of any planned reforms. As the years of inactivity at the national level accumulate, and facing continued under investment and poor management at the state level, the problems that now bedevil our current system will only multiply.

Unlike the GFC, systemic health problems don’t grab daily headlines or demand an immediate response. From a political perspective, postponement of genuine decisions is easy. The extended delays in decision-making by the Rudd Government should present an excellent opportunity for the new Opposition leader. While Tony Abbott has accepted the very popular idea of one level of national health financing, he has also gone back to the future to refloat the 1950’s concept of independent hospital boards.

For those who think the current state-based system is highly dysfunctional, a return to that hospital-centric and locally chaotic system would be disastrous. Sadly, Abbott’s own credentials for instigating real health reform are very limited. In his five years as federal Health Minister, he adopted the position of a true conservative and strongly resisted widespread reform. Consistent with its philosophical approach, the Howard Government used taxpayer funds to underpin private health insurance and backed the growth in personal out-of-pocket expenses.

To date, the Rudd Government has not made it clear which problems in the health system it aims to fix. While the PM has moved enhanced productivity to the top of his list, he has not clearly committed to abolish the principle cause of low productivity in the health sector — the divided Commonwealth-state system of finance and delivery.

From a consumer perspective, the lack of ready access to elective surgery, enhanced medical care, dental care or mental health services for those with fewer resources are stand out issues. The poor standard of care for those with chronic health problems is universal.

The Government has not yet selected a clear method for resolving the fractured Commonwealth-state divide in financing, administration or delivery of services. It has rejected more radical approaches to enhanced productivity such as competitive national insurance schemes. Its only clear commitments are to better resourcing of primary and preventative care. The sharp end of public hospital reform remains largely untouched.

The least empowered person in the current system is the consumer. Among community, consumer and carer representatives the values that could underpin our national system are remarkably consistent. They were outlined to the Rudd Government in the 2020 summit and were reinforced by the National Health and Hospital Reform Commission. Those values put the patient, not the professionals, the government or other business interests at the centre of the health-care system. They also promote equity of access, low out-of-pocket expenses and a commitment to improved health outcomes.

To achieve these lofty goals, national political and local clinical leadership are critical. For more than two decades now, we have seen the erosion of both. As detailed by the Garling review in NSW, local clinical leadership in our public system has collapsed in the face of Soviet-style managerialism. At the national level, leadership has been reduced to support for individual projects such as the Lifehouse Cancer Centre in Sydney. While such iconic enterprises have the potential to drive more responsive patient care, they will fail if not supported by more widespread reforms.

Real reform is not a series of photo opportunities or stage-managed “public consultations”. It’s a tough, long-term and serious piece of work. There are clear lessons to be learnt from overseas experiences. The most important is the central role of informed leadership. Health is a contested business with many vested professional and sectional interests. There is an urgent need to re-engage the community, academic and professional sectors. Those with little background in the system, and those who are deaf to the real concerns of the patients and their families, are left bewildered.

The economic stimulus resulting from the GFC could have been used to drive real reform in the health sector. Unbelievably, new infrastructure commitments were reduced from the original commitment of $5 billion to a spend of just over $3billion. In 2010, the Rudd Government now promises to do more with less. If this shrinking commitment is combined with lack of real reform then we can only expect to see poorer outcomes in key areas such as indigenous health, mental health, aged care and other chronic diseases such as diabetes.

For 2010, my new year’s wish is to see our Prime Minister focus his attention on this key domestic issue. In Australia, we have the necessary component parts (the health professionals, the social values, an established public and charity sector and competitive private insurance and service delivery sectors) to construct a world-leading national system.

What we need is a national Government with the right mix of depth of information and experience. It needs to work actively with community rather than bureaucratic partners and demonstrate its stomach for real reform.

Ian Hickie is executive director of the Brain and Mind Research Institute