KEY POINTS:
All health policymakers and administrators should roast on this spit: "Free can't be the best, best can't be free." Voters in modern rich societies want the best free.
They want it along with tax cuts and despite any self-inflicted damage from eating, drinking and behaving badly.
Minister of Health Pete Hodgson rightly trumpets the improvements that huge heaps of money have bought since 1999, only to find a general public belief that things are below par.
Why? Science keeps delivering expensive new "health" technologies faster than new lower-cost technologies for existing procedures.
So the cost rises inexorably faster than national output, the gross domestic product (GDP). Ministers are doomed to fail amid success.
There is no simple answer. Privatisation isn't it, United States experience tells us. Tens of millions there cannot afford treatment.
And it is staggeringly expensive. Treating real and imagined illness and fixing up damage in the US takes half as much again in GDP share terms as total private and public spending does of our skimpier GDP. Yet Americans' life expectancy is below ours.
Consequently, health services reform is a constant issue in both state and federal politics. Hillary Clinton failed spectacularly during her husband's presidency to fix the mess. Reformist state governors are struggling.
A US study found that 15 per cent of doctors' diagnoses were wrong because of the inexactness of medical science or inattention to patients.
Judging by the experiences of a friend here, who was given different diagnoses and treatments by different doctors, with a resultant setback, I am tempted to give the US figure some credence.
Hodgson's torture is that these personal mishaps and tragedies can readily morph into a national "crisis". The smarter and more complex the technologies, the higher the expectations of infallibility.
Then there's the matter of our training expensive thieves - those who accept large student subsidies then scarper overseas. We have to steal doctors trained in other countries to fill the holes, and hospitals hire locums at high cost.
Add the crony-ridden district "health" boards (DHBs), beset by disruptive unions trying to get nurses and others paid enough to stop them emigrating. Then there is Pharmac, which can't pay for all the wonder drugs lobby groups demand.
Write your own stories, or listen to National's Tony Ryall, Act's Heather Roy and the Greens' Sue Kedgley telling you how sickly the "health" system is.
Yet far more is done to enable far more people to live longer and live more nearly whole lives than 20 years ago. We should feel blessed. Instead we gripe, grumble and groan.
In 15 months or less, like as not, Ryall will get his turn to roast on the spit. Can he square this iron circle of expectations and delivery?
Ryall starts with a near blank sheet. "Health" was too hard for Don Brash so National's blink-and-you-missed-it policy last election is no guide. Ryall has been developing a discussion paper, scheduled for last May but not now likely till September or October. He starts with two guides: minimal restructuring, which diverts professionals' attention from the real job; and a focus on consumer need, "personalised" and "closer to home".
So primary health organisations (PHOs) will stay. "The vehicle is right," Ryall says. "There is a role for an organisation that works to improve and co-ordinate primary services."
Any thoughts of "managed care" systems, which proved too daring for Bill English as Health Minister in 1998, are off the radar. There will be "no upheaval in funding".
The GP subsidy will be "undisturbed". Ryall will, however, "want to see how capacity can be improved". DHBs will also stay. But Ryall wants smarter and increased use of the private sector for "elective" - meaning "waiting list" - surgery. And he wants clinicians more prominent in directing resources.
His model is a system of clinical networks developed in New South Wales.
These are collaborative networks of clinicians spanning hospital and primary-secondary boundaries to better manage resources, particularly for chronic illnesses.
They use a combination of diagnostic and health management "bundles", delegated funding, upskilling, and information management. They have saved money and are claimed to have improved patient outcomes.
Management is not sidelined, Ryall says, but "incentivised to work closely with clinical staff".
This, he argues, means the workforce is less likely to feel marginalised and demoralised and leave the country.
Will that square the iron circle? For sure, no. But there is some fresh thinking, which National's sickly health policy has badly needed.
