Our health care systems are dying under their own weight. They are morbidly obese. They keep on eating up our resources with a voracious appetite. Like clinical obesity, it is not a single problem, but a complex growth that arises from the interaction between our genetic make up, our bodies, our communities and the environment in which we live.

Conducting public polls and appointing an ombudsman to deal with contentious health rationing can provide a way forward.

Historically, our health funders try to trim the fat by restricting services to predefined pathways or through guidance. Scorecards show us some temporary success; services can work more time efficiently, but are they more effective? Even more important, are they appropriate? Curbing clinical time, for example, often results in less opportunity to discuss care options with patients and quicker referrals to expensive specialist services.

Despite the proliferation of guidelines to curb spending and starve these obesogenic practices, not all care can be evidence based and translatable in to reproducible clinical practice. Even when evidence is available, there are problems with uptake and the rapid pace of new clinical advances.

Trimming or transferring services to an alternate funder is another short term fix. Slicing out-of-hospital costs, such as therapeutic communities, residential nursing and home health care just shifts patients with complex problems to nursing homes and gaols.

We need to target our starvation strategies if we want to avoid this yo yo dieting. Leaving it up to clinicians and policy makers hasn’t worked, as both groups are focused on their own particular concerns. Clinicians don’t bear the cost of service provision and so have no direct incentive to change beyond clinical evidence and funders are mainly concerned with meeting short term budget targets.

Communities need greater engagement in discussions to curb these short term fixes. We are all interested in the health care we receive and pay for. However, it is our next decades we need to be planning for. Health care may be complex, but not beyond explanation. Collectively, we should be able to agree on programs that should be advanced and those that are low-value and should be cut, for example, providers need time to explain which patients should not receive treatment, from those who should or could wait. These trade offs could be made by individual patients.

However, engagement and dialogue with individuals and communities is not enough. Recent events in end of life care show that decisions are still left to clinicians, media and even the courts; all of whom have proved inadequate. It is time to look more widely at supporting rational decision making. There are many strategies that can be adapted from other sectors. Engaging the public in polls as we do for governments is just one strategy. Appointing an ombudsman to deal with contentious health rationing is another.