Centre for Health Governance, Law and Ethics 2009 Oration
1 April 2009
From left to right: Mark Ragg, Professor Mary Chiarella, Peter Garling SC, Professor Belinda Bennett and Professor Roger Magnusson
As Commissioner of the Special Commission of Inquiry into the NSW public hospital system, Sydney Law School alumnus Peter Garling SC (BA 1975; LLB 1977) was asked by the NSW government to make recommendations about one of the most difficult challenges facing governments in Australia and around the world: how to contain rising health costs, while meeting the public's expectations around access and service quality. The Commission's Report, delivered to government in November 2008, makes 139 recommendations. They include recommendations for the establishment of three new independent agencies: a Bureau of Health Information, a NSW Institute for Clinical Education and Training, and a Clinical Innovation and Enhancement Agency. These agencies would join the work of the existing Clinical Excellence Commission in driving culture change and monitoring the performance of the public health system.
On 26 March, Mr Garling SC delivered the 2009 Oration of the Centre for Health Governance, Law & Ethics. Speaking to a large audience in the new law building, Mr Garling re-visited the underlying dilemma: the discrepancy between public expectations around health service quality and availability, and the amount of money available to spend on the health system.
At 28%, health expenditure currently accounts for the largest proportion of NSW government spending. As Mr Garling pointed out, this amounts to $36 million per day, or $1.5 million per hour. The health system also faces sharp cost pressures in future, particularly due to the health needs of an ageing population. Based on current trends, unless the rate of growth in health system expenditure is curtailed, by 2040 health spending will consume 100% of the annual budget.
Something needs to be done. But there can be few more ethically and politically charged issues than deciding whose health care needs should lose priority, relative to the needs of others, and ultimately to other government priorities. As Mr Garling pointed out, there are alternative solutions, such as raising taxation or charging patients for services received in public hospitals - and thereby sacrificing the principles of free and universal access. But these are less feasible than the option of modifying what Australians are able to claim from the public hospital system in the light of budgetary constraints.
A key theme in Mr Garling's oration, titled "Sharing caring in a time of budget insufficiency: is there an ethical reform paradigm?" was that the big questions about health resource allocation themselves constitute a reform process that must be approached in a rational and systematic manner. In Mr Garling's view the key to successful reform lies in "starting with achievable small steps, and then developing to embrace the larger and more difficult decisions rather than the reverse".
Peter Garling SC
Enablers and impediments to reform
Enablers of the reform process include, firstly, better information. The Garling Commission recommended the establishment of an independent Bureau of Health Information that would systematically measure the performance of service delivery in hospitals, including safety and quality, and patient outcomes. Another important enabler of reform is the development of an agreed process for debating and agreeing on rules for the sharing of resources.
The impediments to reform, Mr Garling told the audience, include the fact that there is no right answer to the challenge of health resource allocation: "One is entering the field where economic rationalism comes face to face with individual standards of morality, individual values and a multitude of different perspectives....Should the Baby Live? And Should the Grandparents die? There is no single and obvious answer to these questions".
Professor Mary Chiarella, Professor of Nursing, University of Sydney
Four recommendations for reform
Mr Garling outlined four recommendations for reform in his oration. Firstly, he recommended the design and implementation of evidence based protocols for clinical interventions, as agreed by a broad network of clinicians through a process of consensus. Importantly, these standardised models of care for each disease, or typical surgical intervention should be made public, so that the community knows what kind of care they will receive in a public hospital. Mr Garling acknowledged that standardised care models do limit clinician's choice, but he emphasised that standardised medicine does not mean sub-standard care.
Secondly, Mr Garling recommended a 25 year plan describing and guiding planning towards the capital investment and fixed resources necessary to support the effective implementation of these protocols and models of care. Long term planning avoids the demands of sectional interests and the volatility of the political cycle. Thirdly, Mr Garling pointed to the need for the public to become more involved in their own care, with greater use of living wills and mechanisms for formalising patient choice around the use of the expensive technology that characterises much end of life care. Finally, Mr Garling proposed the development of a Charter of Patient Rights "which makes it plain what it is that a patient and their family can expect to receive from the public health care system".
2009 is the 200th anniversary of Charles Darwin, and Mr Garling concluded by pointing to what Darwin said, nearly 150 years ago: "It is not the strongest of species which survive, nor the most intelligent, but the ones most responsive to change".
Mark Ragg, Adjunct Senior Lecturer, School of
Sydney Law School's Health Law Programs
The Garling oration represents one of a number of conferences, orations and seminars that the Centre for Health Governance, Law & Ethics hosts each year, to reach out to the community and to engage with current issues. Sydney Law School offers a popular Master of Health Law (MHL), a Graduate Diploma in Health Law, and a Graduate Diploma in Public Health Law that is available to law graduates, health professionals, and other approved applicants.
For further information about the health law teaching program, contact either of its co-convenors, Professor Roger Magnusson (R.Magnusson@usyd.edu.au) or Dr Kristin Savell (K.Savell@usyd.edu.au). For further information about Centre activities, contact the Centre Director, Professor Belinda Bennett: B.Bennett@usyd.edu.au. For application forms and other information about enrolment, contact Ms Sue Ng, head of the postgraduate team (S.Ng@usyd.edu.au).
Contact: Greg Sherington
Phone: +61 2 9351 0202