The proposals for comprehensive primary health-care centres, divisions of primary health care and performance payments seem guaranteed to upset all the doctors' groups, but perhaps, just for once, the needs and wishes of patients and the community will prevail.

Yet the proposed reforms to primary care are undermined by a failure to deal with patients' problems in getting timely and affordable access to out-of-hospital specialist care; the continuance of fee-for-service for many primary-care services; and the extremely cautious approach to allowing access to Medicare reimbursements for health professionals such as nurse practitioners and midwives, even those who provide care where doctors are scarce.

It's not clear why the commission is so accepting of current levels of out-of-pocket costs and rising co-payments, which are a severe impost for many sick Australians and have been demonstrated to impede compliance and continuance with treatment and medication regimens.

The commission acknowledges that mental illness requires a unique approach to the provision of services and care, and makes strong recommendations for early diagnoses and intervention as well as coordinated services for young people and those with psychoses.

But there is an inexplicable failure to integrate mental health into primary care, and the serious deficiencies and inequities in current Medicare mental health programs are ignored. There is no recommendation for the coordination of services across governments and bureaucracies, as essential for mental health as it is for aged care.

The report makes all the right recommendations about training more health professionals, but the reality is that, unless poor pay and working conditions are remedied, retention rates for staff in public hospitals, mental health, aged care and remote regions will continue to be low, undermining new initiatives.

A conclusive position about which level of government should fund and operate public hospitals has been postponed to the final report, and thus will not be public when implementation of the new health care agreements begins on July 1. This report is silent on how the performance indicators previously developed for these funding agreements should be implemented and assessed.

It is to be hoped the commission will continue to explore and expand the options canvassed and not be deterred by the noisy debate that has already been joined by some groups and individuals.

Reforming and refocusing health-care systems is difficult, and new ideas provoke stakeholders' prejudices and vested interests. The best recommendations of an expert committee will still require tough decisions, strong leadership and some battle victories by the Prime Minister and the Minister for Health.

Dr Russell is the Menzies Foundation Fellow at the Menzies Centre for Health Policy, University of Sydney and Australian National University.