We may lament, as Melissa Sweet does, the characteristics of the health debate – always focussed on $$, always reinforcing the power relationships in health service provision in which doctors dominate – but that is the nature of the debate.

We may even wish we could change it – as she does and I certainly do. But this is probably not within our gift. Sometimes as an alternative to financial preoccupation we are urged to discuss ‘matters of principle’.

However, my friend and colleague, former senator and doctor Peter Baume used to observe, in the world of politics ‘matters of principle generally turn out to be matters of money, and matters of high principle are usually matters of lots of money.’

But all is not lost. Two forces are visible that will drive change in the system and in the health debate even though both, to a fair extent, have to do with money.

Before examining those two forces, we must recognise that at present the fee-for-service system suits the majority of health care providers and the majority of patients who do not need continuing care and wish to be able to purchase access to a primary care provider without let or hindrance. That the system meets these needs is apparent in the high levels of satisfaction expressed by patients and doctors with these arrangements.

Problems with this system emerge only when one is concerned about questions of equity of access and efficiency of care (the example of refugees at Coffs Harbour, Indigenous health, rural and remote health care), or when the needs of people with chronic illness surface, as they are doing with increasing frequency.

The first force that will drive change is a demographic shift that will alter the politics of health care. The interval 2007-2020 is the period of fastest transition in ageing in Australia, as the boomers reach 65. By 2038 the number of people aged 51+ will exceed the number aged 50 or less, and the political dynamic of this will be strong. It is probably then that the political pressure to change the form of our health system will peak.

The second force for change is the realisation that we are wasting resources at present and that this is costing patients length and quality of life. The Commonwealth and states are in serious debate about the way that publicly funded health services are managed between them in the quest for greater efficiency.

These discussions will drive the system in the same direction – towards stronger relations among the various care providers in the community and in hospitals and a weakening emphasis on stand-alone care that is paid for by fees at the time of use and which does not necessarily connect to any other services beyond its walls.