Remedies for a health system in crisis

After a 10-month investigation into the NSW Public Health System, Commissioner Peter Garling warns of a system at breaking point. In its first year of office the Rudd Government has already introduced some measures to relieve the burden. Now the onus is on the NSW State Government to implement Garling’s recommendations and allocate resources where they are needed.

After a 10-month investigation, Commissioner Peter Garling SC has delivered a report that identifies the problems and challenges confronting the NSW public health system.

At the same time the Rudd Government has significantly increased its share of federal health funding that had shrunk dramatically under the Howard Government.

Federal Health Minister Nicola Roxon has shifted policy settings to a wellness model with an emphasis on preventative health and primary care.

And as part of its economic stimulus package, the Federal Government has established a health infrastructure fund to finance the development of the health system at the macro level.

In the medium to long term these changes should reduce the burden on our public hospitals.

The onus now falls on the NSW State Government to implement the Garling Report’s recommendations and allocate resources where they are needed to get our public hospitals functional again.

Garling reports back on public health

After a 10-month investigation into Acute Care Services in NSW, Public Hospitals Commissioner Peter Garling has handed down a report that warns of a system at breaking point.

During the course of his inquiry Commissioner Garling visited 61 public hospitals, heard evidence from more than 600 people and received over 1200 written submissions including one from the NSWNA.

The full report is 1100 pages long and includes 139 recommendations.

The report has been positively embraced by a broad spectrum of stakeholders in public health as a cogent analysis of the problems facing the system.

In December 2008 NSW Minister for Health John Della Bosca convened a forum comprising community representatives, health system managers, clinicians and industrial organisations, which endorsed 90% of the report’s recommendations.

The NSWNA was represented at the forum by General Secretary Brett Holmes.

‘Commissioner Garling clearly acknowledges the key role of nurses in the system and how hard they work,’ he said.

‘Many of his thoughts on the role for nurses within the system are consistent with positions that have been taken by the NSWNA: that experienced nurses are crucial in the workforce and need to be recognised and adequately remunerated; that Nurse Practitioners are capable of taking on some of the roles of doctors; and that nurses’ skills could be more effectively used than they are currently.

‘We believe that if this report’s recommendations are implemented nurses can be optimistic about having a better and more sustainable workplace’

Why there is a crisis

In his report Commissioner Garling was at pains to point out that NSW has an excellent health system that is world class but that there has been a sudden and dramatic increase in the number of people using it.

‘In my opinion the looming crisis for public hospitals has happened so quickly that it is not surprising that the organisation has been slow to implement radical reform,’ he said.

The upsurge in numbers lining up in our hospitals is particularly dramatic among the old. In 2006-2007 one third of all public hospital patients were aged over 65 years although that group made up only 13% of the population. Now, those aged over 65 make up 45%, nearly one half of all hospital patients.

The report says young people are also turning up at hospitals in greater numbers especially in Emergency Departments. A significant number may have mental health problems along with drug and alcohol dependence.

Four pillars of reform

Garling has recommended four pillars of reform required by NSW Health to adapt to the serious challenges confronting it:

  • A Clinical Innovation and Enhancement Agency;
  • A Clinical Excellence Commission;
  • An Institute of Clinical Education and Training to keep learning and skills updated in an era of unprecedented change in healthcare;
  • Establishment of a Bureau of Health Information to ‘access, interpret and report on all data relating to the safety and quality of patient care and facilitate its interpretation and reissue to the unit level on a regular basis’. Commissioner Garling emphasised that this bureau should stand independent of NSW Health.

These ‘pillars’ would be underpinned by the introduction of an up-to-date information technology program, which would allow an audit of the performance of all hospitals in the compilation of patient clinical records and lead to a state roll out of an electronic health record.

‘All of the leading world health experts I spoke to told me that understanding, analysing and publishing sensible health information is the basis for knowing where health care in hospitals is at, where it has to go, and when it has arrived,’ Brett said.

A more effective role for nurses

Garling highlighted a serious challenge: 22% of the entire nursing profession in NSW qualifies for retirement in 2011 – only three years away. He also points out that nurses in public hospitals are frequently junior nurses with insufficient senior nurses to supervise them.

Garling emphasised the importance of redesigning the role of the Nursing Unit Manager so a NUM can take leadership in the delivery of quality patient care. Garling set a target: 70% of a NUM’s time is applied to clinical duties and no more than 30% of time is spent on administration, management and transactional duties.

Garling recommended the creation of a Clinical Support Officer, to cover the roles previously performed by communications clerks, ward clerks and wardsmen, so NUMs are freed up for clinical work.

Other important recommendations relevant to nurses were:

  • the creation of a new clinical classification for RNs with more than 10 years experience, including an appropriate pay increase;
  • more funding for nurse practitioner positions across NSW, particularly in rural and remote areas where it is hard to employ doctors;
  • a redesign of the workloads tool to take into account skill mix and years of experience.

It’s about patients

The Garling Report doesn’t mince its words about the culture of the health system and clearly warns that the system is at a crossroads.

‘We have entered into a period of crisis for a public hospital system which has always been free and accessible for all,’ it says.

‘A new culture needs to take root which sees the patient’s needs as the central paramount concern of the system and not the convenience of the clinicians and administrators.’

The NSW Premier Nathan Rees has promised a response to Garling’s report by March.

‘This is a major report recommending far reaching changes in the way we deliver health care in the face of demographic change and rising costs,’ he said.

‘The report provides us with an action plan to deliver improvements in the delivery of acute care across the state.

‘I want to thank the nurses, doctors and all the families who gave evidence, which I know was a difficult experience for some. I give them my personal assurance that we will follow through on this report with action.’

Have your say on the Garling Report

NSW Health has created a website that allows interested community members and the health workforce to provide comments on each of Garling’s recommendations. The site can be found at

http://healthactionplan.nsw.gov.au; or from a link at the NSW Health site http://www.health.nsw.gov.au/

You can read the report and its recommendations on this site. There is also a facility to make your comments directly on the website.

Health the winner in Rudd’s ‘new cooperative federalism’

The Rudd Government has agreed to pump an extra $4.8 billion into the country’s health system with NSW taking the largest slice.

The extra money announced at Commonwealth–State funding talks, takes total Federal funding for health and hospitals to $63.6 billion over the next five years.

In addition, the annual increase in funding has been boosted from 5.7% to 7.3%.

The extra funding does something to redress the imbalance in responsibilities for health funding between the State and Federal governments that arose under the Howard Government.

The original health funding agreements had a 50/50 split in funding between the states and Canberra for public hospitals. By the end of the Howard Government, Canberra’s contribution had dropped to 40% with the State Government forced to take up the slack.

The health increase is part of a bigger stimulus package for the economy and was welcomed by NSWNA General Secretary Brett Holmes.

‘The global financial crisis has created a situation where the immediate priority for governments is to spend money. This need for a large-scale stimulus is recognised by a wide range of economists,’ he said.

‘There is no better way for the Government to spend large amounts of money than fixing our public health system. Jobs created in the sector would provide a substantial boost to the economy.’

Health stakeholders fast track key recommendations

An initial consultation forum of over 120 participants including community representatives, managers, clinicians and professional and industrial organisations, including the NSWNA, took place on 15 December 2008 to discuss the Garling Report.

Over 90% of the recommendations received support from the participants. Some of the recommendations endorsed by the forum for immediate attention include:

  • ensuring multi-disciplinary communication through daily ward rounds in hospitals;
  • planning patient transfer from hospital to home or other care through early planning and better quality advice;
  • redesigning the role of Nursing/Midwifery Unit Managers to free up time for patient care;
  • improving hand hygiene across the healthcare team;
  • making sure overseas doctors and nurses have good induction to the workplace.

Other key areas of agreement include:

  • creation of a position titled Clinical Support Officer to encompass roles previously performed by communication clerks, ward clerks and wardsmen;
  • the establishment of a non-urgent transport systems for those patients requiring assistance to home or non-urgent transfer between facilities;
  • establishment of a Health Information Bureau.

Rudd’s increased commitment to health

  • An extra $4.8 billion for health.
  • Federal funding to states for health and hospitals increases to $63.6 billion over the next five years.
  • Health care funding to states to rise by 7.3% per year.
  • $1.1 billion to train more doctors, nurses and allied health professionals.
  • $750 million to improve service in public hospital emergency departments.
  • An extra $800 million for Indigenous health.
  • An extra $450 million for preventative health.
  • NSW was the big winner receiving one third of the entire national stimulus package.

Lack of clinical places limits uni uptake

A report by the National Health Workforce taskforce has revealed that only 200 of the 500 extra university places for nurses created by the Rudd Government last year have been filled.

The major stumbling block has been the lack of funding and capacity for clinical training. The NSWNA warned at the time that the shortage of clinical placements would be a barrier.

The problem of clinical places has been tackled by the Federal Government in its $1.1 billion health workforce package.

There is a $500 million component to increase the number of clinical places across the health workforce and in public hospitals.

The package will also fund the training of 18,000 nurse supervisors.

What nurses and midwives say about the Garling Report

Hannah Dahlen, Associate Professor of Midwifery, University of Western Sydney, spoke to the Garling inquiry.

‘Garling “got” the issues about midwifery. He “got” the issues about continuity of care, caseloads, about private practice midwives access to hospitals and about insurance.

‘He’s made recommendations that are very workable. Whether the Area Health Services and NSW Health implement them is another thing.

‘Garling’s report comes at a pertinent time in history with the midwifery review about to come out as well. The time is right to expand the midwives’ role.’

Carolyn Hook, NUM, Prince of Wales Hospital, said the Garling Report is a good report that focuses on the problems faced by people at the coalface.

‘NUMs definitely need administrative support. It has been dwindling rapidly. An 80:20 ratio between clinical work and administrative work would be better but the 70:30 ratio that Garling recommends would be much better than now. NUMs are not replaced on the ward if we are down so it will help other staff on the ward if we are available to do clinical work.’

Lorna Scott, Nurse Practitioner, said some of the recommendations are great but it will be tricky to put it into practice.

‘I’m a little bit pessimistic when you see some of the cutbacks going on. Garling could have done more and looked at a revamp of the Area Health Services. His comments about Nurse Practitioners are excellent if they are implemented.’