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NSW Health: Garling Report « Previous | |Next »
November 28, 2008

On the eve of CoAG there is the promise for extra Commonwealth funding for health care in the form of a new five-year health funding agreement between the Commonwealth and the states designed to end the blame game.

The states' demands are for extra funding. They are seeking a more realistic indexation arrangement and a restitution in the key area of public hospital funding of the 50-50 funding split that was eroded under John Howard and Peter Costello. The federal government funds about 42 per cent of public hospital services. The states are also seeking a one-off catch-up payment to reflect poor deals in the past on public hospital share and indexation.

More than extra funding is needed. The recently released Garling Report into hospitals in NSW indicates that the states need to reform the way health is delivered. Commissioner Peter Garling, SC, said that though the NSW had a public hospital system of high standard, that system was on the brink of collapse:

Given the demographic changes and the rising costs, it is the case that we have entered into a period of crisis for a public hospital system which has always been free and accessible to all. If public hospitals are to survive as providers of free care for all, there will have to be some radical changes in the way they do business. We are on the brink of seeing whether the public system can survive and flourish or whether it will become a relic of better times. To start with, a new culture needs to take root which sees the patient’s needs as the paramount central concern of the system and not the convenience of the clinicians and administrators.

So it is not just a case of more money from the Commonwealth to maintain real rates of growth in funding in the face of an ageing population and technological change. Radical changes are needed. What are these?

For Michael Costa this involves the federal Government having responsibility for all aspects of national health care, including funding and administration of the public hospital system. Plus hospital-level competition on quality and cost effectiveness of service provision should be introduced with resources flowing to the best hospitals.

Garling takes a different tack. He says radical reform includes new models of care at the clinical unit level at the state level:

The doctors, nurses and allied health professionals will need to replace the old system where different specialists would see the patient but no one person would necessarily take complete charge of the patient’s care. A new model of teamwork will be required to replace the old individual and independent “silos” of professional care. Furthermore, the rigid demarcation between what a doctor’s job is, and what a nurse’s job is, needs to be consigned to history. Once the concept of teamwork is accepted as the norm in treating a patient, it is easier to see why a qualified nurse practitioner should be able to do many jobs once reserved for doctors.

This means the changing of a professional culture and this can only occur if the why and wherefore of reform is taught in the undergraduate and early clinical training years. This means the creation of a modern, well trained, flexible hospital workforce.

This reform needs to be backed up investment in informations technology so that the information collected is to be directed to how well the patient has been treated, not to process-driven, often politically-driven, data which may make administrators more comfortable, but not the patients.

In contrast to Costa's top down reform model Garling says:

that redesign of clinical practices must be a bottom-up reform driven by clinicians; that information about the safety and quality of treatment at the unit level is the greatest guarantee of a quick change-over to evidence based best practice models of care; that the only way to avoid a slide of the present clinical standards into mediocrity or worse is by strengthening the training of new clinicians in better, safer treatments based on a patient centred team approach; that the safety and quality of public hospital care should be the highest priority of the public hospital system, and that its employees need to implement this at the individual patient level.

Garling adds that know that, as a rule, a person with an illness is often better off being treated outside rather than inside a hospital. Of course this does not apply to someone who suffered a serious accident or has taken the wrong medication or is suddenly struck with chest pains. But the bulk of chronic conditions are
better dealt with in the home or in the community than in an acute care bed.

| Posted by Gary Sauer-Thompson at 4:58 AM | | Comments (2)


so Costa wants Rudd to take over the hospitals and subject them to the competitive pressures of the market?

He makes a good point when he says that there is a nationwide disillusionment with state government service delivery and that It it is only a matter of time before this reflects on federal Labor.

The medical establishment is even more resistant to change than school teachers.

Costa's approach is a recipe for chaos.

It is more than 150 years since Dr Phillip Semmelweis discovered the fundamental importance of doctors washing their hands between examining patients, and still some won't do it. This failure is a major cause of hospital-acquired infections.


"Despite recommendations, nearly 60 percent of health-care workers [in the US] do not wash hands while on duty."

Sticks and carrots in the workplace can help, but, as Garling recommends, major reform has to be bottom-up.

(Perhaps that is also true of the teaching profession.)