The health sector is overburdened by those who don't know how to look after themselves or don't give a damn, writes Gareth Morgan.
A few weeks ago in this column I wrote about how there are not enough resources to meet everyone's health needs, and how we needed to start making some hard decisions on rationing - sorting who gets treated and who doesn't.
But rationing is just one part of the puzzle to future-proof our public health system. Indeed the consensus amongst professionals within the health sector, while acknowledging the unsustainable nature of the ad hoc and totally unfair rationing that goes on now, holds that by far the biggest issue is the insatiable demand for health services.
If we could address the main drivers of that demand then our health resources wouldn't be so stretched.
Increasing numbers of oldies is one source of the unbridled growth in demand but it's not the main one. It is the public's expectations of the public health system that is the big problem.
We ignorantly think it's an "all you can eat" system, that we can expect it to deliver anything we, or our doctor, might consider we need.
That is a misconception, there are already demands on, and expectations of, the system that cannot be met now. But when we look ahead it's the drivers of the growth in our demands that are the most revealing.
Right up there for example is the growth in chronic (untreatable) conditions. Indeed the increasing numbers of folk with multiple chronic conditions, whose demands on the health system know no bounds, is arguably the most frightening aspect of the burgeoning stress on the system.
These multiple chronics arise because of inadequate health education and in some cases deprived basic sanitation conditions.
As a rule of thumb, a dollar spent on prevention or early intervention produces four times the return as does a dollar spent on hospitals. It's no contest, we need to spend more here and less on hospitals.
Politicisation of health is so acute here that the political will to invest enough in our future health is minimal. Better to get kudos for instant solutions for today's perceived problems.
Our politicians (who to be fair only reflect the preferences of you and me, the voting public) myopically over-spend on high-profile, attention-grabbing, show-off now, hospital solutions.
To hell with the preventative stuff - no votes in that! The political bang is in funding the ambulance at the bottom of the cliff, not the safety barrier at the top. This, more than anything, is why de-politicisation of health prioritisation is urgent.
Consider the public's demands.
Insatiable appetite is right - not only do we want to have our cake and eat it, we expect the health system to pay for the stomach stapling surgery to boot. When it comes to obesity for example, there are a number of ways that we can reduce our appetite for last-resort help, but if we'd only kept our gobs shut to start with, the need would be so much less.
Or contrast our policy approach to booze and smokes. With smokes we did a fine job on prevention - we stigmatised it - faggers leave the premises; we taxed it - excise duties have made it a costly indulgence; and finally we educated - "smoking kills" campaigns. A potent triad indeed.
Contrast that to booze. The price has fallen markedly over the last decade, the drinking age has been lowered and our culture is to "celebrate" binge drinking as an induction to adulthood. The result - an unpleasant and unnecessary load on the health system.
The only line of defence in the way of us collectively being drowned in an alcoholic stupor, has been the successful "don't drink and drive" initiatives which have actually worked. Overall our approach to booze has been pathetic. It's beaten us.
Most of the best things we have done to procure health gains in the last century have had nothing to do with what we normally think of as healthcare. Better nutrition, housing and sanitation have all added countless years to life expectancy and quality of life.
With the single exception of smoking, these days it seems we are doing the best we can to unwind all that good work. As well as binge drinking you can now add obscene portions of cheap, nutritionally-bereft and calorie-rich food.
Portions are rapidly approaching American levels, and are washed down with vast quantities of soft drink, which alone contain enough sugar to keep us high for the day. Given our devotion to driving cars everywhere we go, and our day jobs being spent at computer screens, there's little prospect of us working the calorie overdose off. The rise in bariatric surgery highlights the trend. While these operations are cost-effective compared with a lifetime of diabetes complications, they are still not cheap at around $25,000 a pop.
Government's negligence in addressing the obesity crisis results in a high price long term - today's fat kids are the diabetics, kidney dialysis and bariatric surgery recipients of tomorrow. Such cotton wool politics does the public no favours - protecting those who think they have a right to scoff their body weight in pies simply aggravates the spread of chronic obesity.
Again the solution is simple - tax, education and stigma. Impose excise duties on low nutritional food (use the revenue to subsidise whole foods if you like), play dramatic ads of grossly obese people stuffing their gobs and scoffing diet drinks (whose ingredients simply stimulate appetite), and like smokers, have them go outside to eat.
The fact of healthcare is that a few people in the population create most of the cost; how you deal with these people makes all the difference. Some health systems around the world have the issue nailed. They analyse information about the population and spot who might be at risk.
Then they work with those people proactively (including making them accountable for their actions) to manage that risk and keep them out of hospital. That's where primary care has to go.
Taxpayer subsidies to GPs who aim to see as many patients as they can each day is a totally perverse approach to effective primary healthcare, that conflict of interest standing in the way of effective prevention. Better to directly pay those most at risk to improve their self-management than waste the money on pseudo-entrepreneurial GPs.
The changes required to dramatically reduce the future demand for healthcare aren't rocket science.
But for now we are happier living our unhealthy lifestyles, secure in the misconception that an ambulance stands ready to whisk us away for the best of medical help. If we took prevention seriously, fewer of the tough rationing decisions would be required, access to care would not be such a lottery, and we would live longer, quality-adjusted lives on our own volition.
Prevention is the best medicine.
Gareth Morgan is director of Gareth Morgan Investments, and, with Geoff Simmons, author of the book Health Cheque, a study of the NZ health system.