Dr Tony Webber, a GP who until recently headed the Medicare watchdog, the Professional Services Review, has kick-started a long overdue debate, about waste in health spending. In an article in The Medical Journal of Australia, Webber estimates that $2-3 billion dollars are wasted annually through misuse of the Medicare Benefits Schedule, Pharmaceutical Benefits Scheme and the Medicare Safety Net. For this he blames poor public policy (for example, he calls the Medicare Safety Net "one of the most poorly thought-through pieces of health legislation") and the practices of a "minority of unscrupulous and greedy practitioners". General practice management plans, team care arrangements, obstetricians, ophthalmologists, gastroenterologists and cardiologists receive particular mention as being involved in inappropriate use of public funds. There is also a jab at the health bureaucracies. Webber says his efforts to tell the Department of Health and Ageing (DOHA) about cost shifting between the states and federal government fell on deaf ears, despite it being against provisions in the Council of Australian Governments National Health Care Agreement. "When this was pointed out to officers in the DoHA, I was told not to say anything," Webber writes. Predictably enough, the AMA and federal government have been pouring buckets of cold water on to the media fire ignited by Webber’s article. Rather than being dampened, however, this is a conversation that deserves to be made far more wide-ranging. Some media reports have focused on concerns about a few "bad apples". This focus is too narrow, for a few reasons. First, what some might call "rorts", others might call a rational business response to policy-driven incentives. As the adage goes, every system is perfectly designed to produce the results that it does. Too often we seem to forget in debates about our mythical "health system" that much healthcare is provided by private interests, whether private practitioners or companies. Indeed, one of DoHA’s goals, as reported in its annual reports, is to support "affordable quality private health care". It should not be at all surprising that financial imperatives influence how services are delivered as well as professional practice. Another reason for broadening the discussion beyond "bad apples" is that waste takes many forms. One area deserving systematic attention is the use of unnecessary or inappropriate tests and treatments. For those who doubt the extent of these problems, see this new Croakey project, Naked Doctor, which is a measure of the growing interest internationally in over-diagnosis and over-treatment. It is a project of Dr Justin Coleman, a GP who works in Aboriginal and Torres Strait Islander health in Brisbane and is president of the Australasian Medical Writers Association. Webber highlights a lack of systematic policy efforts to tackle inappropriate spending. I have previously suggested at Crikey that a far-sighted minister or government might set up The Less is More Institute to identify and advocate for initiatives to reduce the use of health services that are unnecessary, harmful or not good value. This is not simply about the bottom line, but also is important for equity and patient safety (the Institute of Medicine in the US has identified overuse as one of three critical dimensions to patient safety, the others being underuse and misuse). It is also about maximising population health. Indeed, a senior health service manager, Dr Patrick Bolton, a national councillor of the Australian Healthcare and Hospitals Association, recently asked whether we might get better health returns from disinvesting in healthcare in order to be able to invest more in areas such as tackling global warming or in promoting greater equity. Then there is the waste caused by overly onerous red tape, a particular problem for indigenous health services, as highlighted by Judith Dwyer and colleagues in The Overburden Report: Contracting for Indigenous Health Services report. There is the waste caused by inflexible work practices and resistance to workplace reforms, as is so well illustrated by our seeming incapacity to make effective use of the physician assistant role. There is the waste of a system that too often burns out those well-intentioned professionals, managers and others trying to do the right thing in the face of complex, inflexible systems. There is no one party or "bad apple" to blame for waste. Adelaide surgeon professor Guy Maddern has also described waste caused by no-show patients at outpatient clinics and says, "worse still, failure to attend for elective surgical procedures is a scandal which receives little publicity". When I see how the digital revolution is creating greater productivity, innovation and transparency in my own industry (while also damaging business models and creating uncertainty and insecurity), I wonder how much longer the health industry can avoid the crunch that surely is heading its way. If the digital revolution can fell a dictator such as Hosni Mubarak, then surely it also has the potential to bring some much-needed changes in the health sector.