Public Hospital reform in NSW

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The NSW government instituted an inquiry into the public hospital system of NSW. Undertaken by a lawyer, Peter Garling, the report resulted in 139 recommendations. The government has responded by accepting 134 of these.

Purpose of health policy or idea

The purpose of the Garling Inquiry was to inquire into the safety and quality of care available in the NSW public hospital system. The inquiry was conducted by a lawyer and gathered information by visiting public hospitals and hearing verbal evidence from individuals as well as receiving written submissions from individuals, groups and organisations. In addition, Mr Garling received extensive briefings from the Department and from each of the Area Health Services (AHS) in NSW.  He also attended a 2-day international conference and a 1-day conference on paediatric issues. The inquiry was supported by a small secretariat from the NSW  Department of Health.

Main points

Main objectives

The objective of the inquiry was to investigate the safety an quality of care within NSW public hospitals. It is also likely that the inquiry fulfilled a political objective as the government had been under pressure for many months over a number of safety and quality issues at various public hospitals in NSW, a number of which were characterised by extensive media coverage of incidents which affected individuals.

Type of incentives

The government had an incentive to initiate the inquiry as this silenced its critics (for a time). Members of the public, patients and providers had an incentive to cooperate with the inquiry as many believe that the system is in need of reform. However, the inquiry has been conducted in an environment of reduced State resources for health services; thus the NSW Department of Health and AHS have little financial incentives to implement any of the recommendations as they are likely to require additional resources. However, they may have political incentives to respond positively to the findings of the inquiry as the findings have been widely endorsed by providers and some influential medical organisations.

Groups affected

The government, NSW Department of Health, Providers of health services working in public hospitals

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

The ratings provided above reflect a degree of cynicism about the extent to which the recommendations will be implemented, as opposed to "accepted". However, even if all are implemeted, they are not innovative, but reflect some elements of best practice combined with some strongly-held opinions of both Mr Garling and/or his advisors.

Most commentators agree that changes are necessary but little impact can be expected as many services will not be affcted, some will only be affected marginally and others may be affected in the future. The Inquiry and the government's response has been well-reported in all sections of the media, making it highly visible. Given that this is a broad ranging report set in the specific context of NSW, some aspects of the recommendations are transferable while others are not.

Political and economic background

The NSW Labor government is perceived as increasingly incompetent. The Labor party has been in power for more than 10 years, a long time by Australian standards and many expected the goverment to change hands at the last election.

Although most of the funding for public healthcare services comes from the federal government, the States and Territories are responsible for running the public hospital system. Thus, they are always susceptible to charges of incompetence and under pressure from the media, the general public, patients and providers over individual issues relating to funding, organisation (such as waiting lists) and particularly, issues of quality and safety. A number of such issues which happened over a number of months finally forced the government to act. 

Surprisingly, they appointed a lawyer (rather than an independent health expert, or team of experts) to undertake the inquiry, with the result that the process was handled rather like a legal investigation- with all "witness" statements taken at face value ie as representing evidence from a legal rahter than from a health perspective. The government has responded by convening a forum of community representatives, health system managers, clinicians and unions to develop advice for it about the priorities for response. Since then, all health services and the NSW Treasury have been asked to advise on the costs of implementing the recommendations. Finally, in its official response, the NSW Department of Health has produced a 43 page response in which it "accepts" 134 of the 139 recommendations of the Garling Report.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The idea of an inquiry into the health system or a part of it is not new in Australia (and many other countries). It is often a response to sustained political pressure from a number of fronts. However, to have a one-person inquiry and for that person to be a lawyer is unusual. It is not clear why the government chose to ask a lawyer to conduct the inquiry.

Initiators of idea/main actors

• Government: The government initiated the inquiry following a number of safety and quality issues

• Providers: Providers saw the inquiry as an opportunity to push for reform

• Patients, Consumers: Patients and consumers used the inquiry to detail the problems they had encountered in NSW public hospitals

• Media: The media were the conduit for the initial complaints coming to the attention of the public. Some evidence given to the inquiry was reported and there has been limited coverage of its recommendations.

Approach of idea

The approach of the idea is described as:
renewed:

Stakeholder positions

No opposition was voiced towards the inquiry. The progress of the inquiry (Mr Garling visited many hospitals and convened public hearings) was followed with moderate interest by the media, especially when complaints from individuals formed part of the evidence provided to the Inquiry.

The report of the Inquiry has listed 139 recommendations (not prioritised). In summary, Mr Garling reported that, in his opinion, the NSW public hospital system was good by world standards, in many cases ranking towards the top but often unable to deal with sudden increases in patients, the rising costs of treatment and the pressures on a skilled workforce often spread too thinly and too poorly supported in undertaking many administrative tasks which take them away from patient care. He also indicated that the system was on the "brink of a crisis" and that his solutions would pull it away from the edge.

The core of Mr Garling's recommendations are the establishment of three new agencies, in addition to the already established Clinical Excellence Commission. These are the Clinical Innovation and Enhancement Agency, The Institute of Clinical Education and Training and the Bureau of Health Information.

The government through the NSW Department of Health has formally responded to each recommendation in the form of a 43 page document called "Caring Together: the action plan for NSW". However, reading the fine print behind the "accepted" indicates that for many of the recommendations, the idea will first be subjected to a further loop of review. The most common wording to indicate this is "Consultation indicates that further consideration be given to this recommendation in relation to functions". Further, many of the "accepted" recommendations are accompanied by a statement indicating that the Department considers that is has alrady or is in the process of implementing the recommendation - even if this is not in the exact form recommended by Mr Garling.

Actors and positions

Government
Government	very supportive		strongly opposed
Providers
Providers	very supportive		strongly opposed
Patients, Consumers
Patients, Consumers	very supportive		strongly opposed
Media
Media	very supportive		strongly opposed

Influences in policy making and legislation

Some legislative changes may be needed to implement some proposed reforms such as setting up some new organisations eg the NSW Bureau of Health Information, NSW Institute for Clincial Education and Training, a NSW Children's and Young People's Health Authority.

Legislative outcome

pending

Actors and influence

Government
Government	very strong		none
Providers
Providers	very strong		none
Patients, Consumers
Patients, Consumers	very strong		none
Media
Media	very strong		none

Positions and Influences at a glance

Adoption and implementation

The 139 recommendations made by the inquiry cover the following areas:

• Patients
• Chronic and complex care
• Mothers
• babies, children and young people
• Rural areas
• Doctors
• Nurses
• Allied health and pharmacy
• Education and training
• Workplace reform
• Bullying
• Supervision of junior clinical staff
• Clinical records and IT
• Communication
• Safety and quality
• Key performance indicators
• Hospital acquired infections
• Deteriorating patients
• Emergenc departments
• Community health
• Surgery
• Funding
• Hospitals

The response to the government's reponse has been cautiously optimistic on the part of providers and some policy commentators. But three of the most contentious issues (how to manage low-risk pregnancies, the amalgamation of current paediatric services into one service (including one hospital) and the process of treating patients in Emergency Departments) are not yet decided.

The government has committeed to reviewing every public hospital in NSW in terms of safety and viability; this is likely to lead to further recommendations to downgrade or close some small rural hospitals.

The government has rejected two recommendations - refunding patients' costs for medication needed to treat hospital-acquired infections after discharge and the creation of a non-paramedic trained driver posiiton for the ambulance service.

Other responses include:

• Staff to go through a "workplace culture improvement program" to cut down on bullying. 
• An executive medical director will be appointed in each major hospital to improve relations between bureaucrats and staff. 
• The roles of senior nurses and midwives will be modified to help improve patient care.
• The bulk of administrative and paperwork duties now done by nurses will be taken over by 500 newly created clinical support officers. 
• An extra AUS$6.3 million a year will be spent on hospital cleaning staff to improve infection control. 
• An extra AUS$22 million will be spent over four years to expand out-of-hours and weekend coverage of allied health staff. 
• An AUS $25 million transition-to-work program will be created for graduate doctors, nurses and allied health workers. 
• An extra 20 trainee specialist places will be created in outer metropolitan and regional areas. 
• A Bureau of Health Information will be established to independently provide information on the performance of the health system.

Monitoring and evaluation

Mr Garling recommended that an assurance and oversight process be established to report quarterly to the Minister for Health on the progress of the reforms. This process must be independent of NSW Health, transparent and rigorous and is intended to provide to the Minister, the Parliament and the general public an independent running report card of whether and how well the recommendations are being implemented. No repsonse to this recommendation has been published.

Results of evaluation

Not applicable as yet.

Expected outcome

Each year, NSW spends approximately AUS$14m on health services. The government has committed an additional AUS$485m over 4 years to implement the recommendations of the Garling Report. However, it must be noted that this additional resources have been announced at a time when the health budget is under mush pressure and Area Health Services have been cutting staff numbers. Further, it is not clear that this will improve safety and quality. The hard decisions will come once the review of all public hospitals is complete because some resources can be saved if unsafe or inefficient hospitals are closed. So far, in NSW this has proved difficult to achieve.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

If all the recommendations are implemented, some improvement in the quality of care provided is to be expected. There is unlikely to be any impact on equity (eg in the form of accessibility of services) and as the implementation is likely to be costly (or at best cost-neutral, if the government saves resources by closing some hospitals) and is unlikely to result in any changes to the overall health status of the population, it is not likely to have any impact on efficiency.

References

Sources of Information

Garling P. Final Report of the Special Commission of Inquiry. Acute Care Services in Public Hospitals. NSW Government, November 2008.

NSW Health. Special Commission of Inquiry. Acute Care Services in Public Hospitals. Statement of Outcomes from Ministerial Forum. December 2008.

NSW Government. Government response to recommendations. Caring Together. The health action plan for NSW. NSW Department of Health, March 2009. www.health.nsw.gov.au/pubs/2009/pdf/caring_together_hap.pdf.

Editorial. Health cure more a placebo. Sydney Morning Herald. Tuesday March 31, 2009.

Robotham J. Garling's recommendations must not be lost in policy hell. Sydney Morning Herald March 31, 2009.

Robotham J, Hall L. Prognosis positive say the doctors. SMH March 31 2009

Smith A. Support staff to free nurses from paperwork. SMH March 31, 2009.

Author/s and/or contributors to this survey

Haas, Marion

Suggested citation for this online article

Haas, Marion. "Public Hospital reform in NSW". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/au/a13/5