There are major pressures on established arrangements for health planning, administration and service delivery. These arise from many sources including the increasing information content of health care and increasing information processing capacity and also increasing economic and political pressure to reduce government expenditure. There are major impediments to effective, efficient and well coordinated programs of care which arise within established inter-governmental funding relationships. Most notorious are the decisions to restructure patterns of service delivery simply in order to shift the cost burden to the other level of government. The structures of health service institutions and professions are also changing rapidly.
Hospitals are tightly integrated organisations with increasing constraints on professional autonomy.
The monopsonic nature of professional boundaries is under increasing challenge with policies directed explicitly at encouraging labour force substitution being implemented in several areas. The speed and intensity of hospital inpatient service delivery has increased dramatically in recent years. The falling length of stay and earlier discharge has, in some degree, been compensated for by increasing attention to developing complementary service systems in the community. Private sector service delivery has not been immune from pressures for structural reform. The evidence from the US suggests that such models can effectively constrain servicing patterns and costs.