What’s Garlingesque got to do with health reform?

Professor Jeffrey Braithwaite, Director of the Centre for Clinical Governance Research at University of New South Wales, has provided this analysis of the Garling inquiry into the NSW health system – and also coined a few new additions to the Macquarie:

Garlingesque [noun, gar-ling-esk]: A health inquiry conducted with a flamboyant flourish, rendered into a report with comprehensive findings yet filled with eerie silences.

Verb forms; Garlingesqued, -ing, as in: “If you do decide to appoint him to lead this review of the Health System, Minister, you will find him Garlingesquing from start to finish.”
v. intr: To use the methods or techniques following Garling, 2008.

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Commissioner Peter Garling SC released his long-awaited report on the New South Wales health system last week. In the doing, has he created a platform for meaningful change?

As the dust settles on this document, knee-jerk reactions are giving way to more thorough cogitation about what it all means. [Parenthetically, perhaps this is the difference between journalism and academia].

With time to digest its intricacies, the wonder of this review becomes increasingly apparent. Leaving aside the 64 page overview report, there are three substantive volumes comprising 1,195 pages.

I only met him once during the inquiry, to speak to a submission I made on behalf of my Centre, but is he really one person? Or was the inquiry conducted by the hitherto-unknown Garling quintuplets, all five of whom went without sleep for months to render this magnum opus?

Of course the actual answer, we understand, is that he had a team. But even so, it is clear he presided personally over almost all events, and read everything voraciously. That’s reviewing more than 1,200 written submissions from more than 900 individuals and organisations, listening to 628 citizens in hearings, making 61 visits to public hospitals, conferring with 27 peak bodies, listening to extensive private briefings from the health system and various experts, and conducting two conferences in less than eleven months.

It is quite obvious that Commissioner Garling’s inquiry listened and synthesised well, and he has made many consequential, if mostly predictable, findings. He says multi-disciplinary teams are key enablers of a superior health system, and deserve to be supported. The health system needs more accessible information and evidence to make better decisions. It should be characterised by greater levels of respect amongst stakeholders, and communication needs to be better. Patient safety and quality of care are vital, and this can happen if new generations of information technology are exploited and there is an improved, trained, motivated workforce.

There are redefined roles for paediatrics (an up-to-the-minute children’s mega-hospital is to be designed and built over the next few years), emergency departments and clinicians. New agencies are needed as this kind of change, according to Garling, is beyond the NSW Health bureaucracy, which must steer rather than row, and transform itself into much more of a policy-initiator than reformer.

The report even goes so far as to give them grand titles, but the new agencies are responsible to improve the processing of health information to the system, training and education of clinicians and a key agency to make it all happen. A new-look and presumably financially bolstered Clinical Excellence Commission, which is doing a fine job, will look after quality and safety more comprehensively.

There is more hard-hitting analysis too. Bullying is endemic, as is pressure to get the pesky data about waiting times and lists to be correct on paper, even if timeliness doesn’t get delivered all–too-often in practice. Appendix 8 is a potboiler exposing these kinds of shenanigans, all written in proper legal language.

As you might expect in such a tome, there is a whole lot more detail, but if there is to be criticism levelled at this inquiry it is about what’s missing rather than what’s there. There is no mention of what for many commentators and health system participants is the elephant in the room: micro-management of parts of the health system like code reds in emergency departments, waiting times for surgery and issues of the moment from over-enthusiastic politicians and their staffers trying to keep health out of the news.

In fact, big ‘P’ politics – the kind that leads the health system to be fought over in a tug of war by the government and opposition and, when the government is weak, the government and the media – doesn’t seem to happen much if you read Garling closely.

There is little mention of little ‘p’ politics, too. The tensions inherent in having differing stakeholder interests, institutional rivalries and competing forces amongst service providers remain unacknowledged. Perhaps Commissioner Garling needed one or two political scientists on his team to complement all those lawyers.

Another piece of missing jigsaw is that, although there is to be an entire agency responsible for innovation in and enhancement of the system so that reform can take place and hold over time, and it is to report quarterly to the Minister for Health on progress, no blueprint is provided for how change is to be accomplished by this body. This may be a serious omission.

In my submission to him, I noted that there had been many healthcare enquiries in New South Wales, other Australian states, and internationally, and our research showed that the real problem was not in formulating what should be done. Most of this is well known, although there can be innovative solutions at the margins. The much harder task is how the reforms envisaged should occur, which is these days called, variously, ‘systems change’ and ‘implementation science’. This is particularly challenging, and perhaps the main game. No health system has figured out how to implement reforms effectively and certainly not quickly, no matter how well crafted are the recommendations made which are meant to give this effect. Yet Garling’s recommendations imply a timescale of months and a few years, rather than envisaging reform as generational change.

Still, Garling’s report is impressive. This genre of literature has an interest of its own. We have examined many inquiry reports across the world, and this is one of the better ones. Garling is prone to rhetorical flourish, and he is clearly a man of letters. As one example among many, the divide between clinicians and managers is likened to the “Great Schism of 1054”, when, as everyone knows, the Christian Church went separate ways, developing later into the Greek Orthodox and Roman Catholic churches. Interestingly enough, each side excommunicated the other.
Commissioner Garling is receiving the expected criticism from the losers and support from the winners. Notwithstanding this, he absorbed much about the health system and its complexity, has steered a well-charted course, made few factual errors, and resisted the temptation to change the boundaries of the area health services as a “solution”. For that, patients, clinicians, managers and policy makers in New South Wales should be grateful.

So will this report matter? One way to use all that expertise garnered by Peter Garling is to do something I don’t think has ever happened in any inquiry we have researched. Why not put him in charge of implementing his own recommendations?

Then, though I’ve just coined the term, it could take on an even newer meaning – ‘Garlingesquing’ could come to mean the successful reform of a health system rather than the mere conducting of an inquiry, accomplished with a deal of flair by a person of learning.

And while he is about it, Commissioner Garling can sort out those things about which his report is unnaturally silent.

Jeffrey Braithwaite is Professor in the School of Public Health and Community Medicine, Foundation Director of the Institute of Health Innovation, and Director of the Centre for Clinical Governance Research at University of New South Wales