Some of Aotearoa New Zealand’s most prominent advocates for the Aotearoa public health system have responded to my editorial regarding the current state of the Aotearoa secondary care health system. There is no doubt that this is a complex problem with many drivers and no easy solution. It will not be solved by sound bites but will require significant thought, deliberation and consultation if those in Aotearoa society are to save the Aotearoa secondary health care system. Blaming various factions is unlikely to achieve a solution. Although many of the points are well made, none of the responding authors offer practical solutions to the issues those working at the coalface in secondary care are currently facing every day. Nor is it acknowledged that, like it or not, implicit rationing is a daily occurrence in the Aotearoa secondary health care system. This leads to siloed decision-making that is unfair and unjust, and is at heart of the inequity that exists within the public health system. Part of my initial argument is that if rationing is occurring, then it should be done explicitly, fairly, transparently and follow an ethical process designed by all stakeholders in the community it serves. In their letters, the authors concerned to do not consider that such explicit rationing, when well-designed, may improve the fairness of current system and prioritise those most in need. It does not need to favour the privileged.

Even if the “financial tap”, was fully-opened tomorrow, the issues relating to underlying infrastructure and workforce capacity would persist. Solutions to these will require a decade or more to resolve. Importation and exploitation of overseas medical workforces at a time of a global shortage of healthcare workers hardly seems an ethical solution. Aotearoa needs to be self-sufficient in maintaining a sustainable healthcare system.

I am curious as to why the authors think Aotearoa society has chosen not to invest more in health? Several of the authors have spent their whole career advocating for more healthcare expenditure. Aotearoa has had political parties from both sides of the house in government, both coalition and majority. There have been health professionals within the ministerial health portfolio. So why has the call for more health expenditure fallen on deaf ears? Could it be that the people of Aotearoa do not want to invest more? Do we know? Imagine a young adult in Aotearoa today saddled with student debt, locked out of the housing market, facing rapidly escalating costs of living, saving for their retirement. Now they are being asked to commit more to the healthcare, much of which will be spent on those reaching the end of what’s physiologically possible for a human life. Will they vote “yes” to spending more on healthcare? To stand by and do nothing, and allow implicit rationing to flourish, is equivalent to watching the tragedy of the commons unfold. New processes are required, that will engage the population and health workforce in a meaningful way to facilitate complex decision-making, to ensure a fair and sustainable healthcare system.