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Continuing reform in NSW

Partner Institute: 
Centre for Health, Economics Research and Evaluation (CHERE), University of Technology, Sydney
Survey no: 
(15) 2010
Marion Haas
Health Policy Issues: 
System Organisation/ Integration
Reform formerly reported in: 
Public Hospital reform in NSW
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no


In response to the Garling Report, the NSW Department of Health has created the "four pillars" of reform advocated by Garling: the Bureau of Health Information, the Clinical Excellence Commission, the Agency for Clinical Innovation and the Institute for Medical Education and Training. This report will describe these agencies and evaluate their potential impact on the effectiveness and efficiency of the NSW health system.

Recent developments

The Garling Report (see Survey 13), handed down in 2008, recommended many changes to the NSW public hospital system. However, in particular, it recommended that four agencies be formed which would work together to underpin the reforms overall. The NSW Government agreed to the formation of these agencies and they are now all in place. One is an entirely new agency, one is a "child" of a previous agency, whilst two are continuing agencies, although hitherto not charged with forming any cooperative ties with each other. All are notionally independent of government, although reliant on government funding for much of their operational capacity.

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Characteristics of this policy

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

In the context of NSW and Australia, the formation of these "four pillars" is rather innovative. It is recognised that similar agencies or organisatons are established in many countries. The extent to which they are expected to cooperate is also somewhat innovative. If the performance of the agencies meets the objectives set for them, they are likely to have an important impact on the system. Although the formation of the agencies has been publicly announced, it has not been widely reported.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Initiators of idea/main actors

  • Government: The government has created four new agencies in NSW in response to recommendations of the Garling Report.
  • Providers: Providers were largely supportive of the recommendations of the Garling Report and have been involved in the formation of the new agencies.

Stakeholder positions

There has been little or no opposition to the recommendations of the Garling Report although some scepticism has been expressed about the way in which the government responded to them and whether the government would be able or willing to make the necessary changes.

The formation of the agencies described by Garling as the "four pillars of reform" has been uncontroversial and largely gone unreported. However, they are new and their work has only just commenced so this may change as they produce reports and other outputs.

Many well-known clinicians are members of the new agencies or the relevant Board of Directors. This signals a level of support for the new entities from senior health professionals.

The position of patients/consumers and the media has not changed because there is no indication the media are interested in these changes or that consumers are aware of them.

Actors and positions

Description of actors and their positions
Governmentvery supportivevery supportive strongly opposed
Providersvery supportivesupportive strongly opposed
current current   previous previous

Influences in policy making and legislation

No legislation has been necessary. Some regulations have been enacted to enable the formation of the agencies as independent board-directed entities.

Legislative outcome


Actors and influence

Description of actors and their influence

Governmentvery strongvery strong none
Providersvery strongvery strong none
current current   previous previous

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Somewhat different processes have been followed in the formation of each of the four "new" agencies.

The Bureau of Health Information (BHI) was established as an independent entity (statutory health corporation) with a board appointed by the Minister for Health, to "make hospital data more transparent and enable analysis of information at the local level to improve patient care". It is intended that the BHI will publicly report a range of performance data at the State, Area Health Service (AHS), hospital and clinical unit/service level. It is also intended that the BHI will, over time, develop new measurements to provide a more comprehensive means of judging how patients in NSW public hospitals are cared for. For example, measures may be developed to indicate clinical performance, including the outcome and appropriateness of treatment, safety and quality of clinical care and costs associated with the care provided. It is intended that the focus of the BHI will be on patient-level data that can be used to indicate trends and areas that require improvement. A new Chief Executive has been appointed.

The Agency for Clinical Innovation (ACI) and the Clinical Excellence Commission (CEC) are the "offspring" of entities which already existed. The ACI was formerly the Greater Metropolitan Clinical Taskforce (GMCT) and the CEC has not changed its name. A common Board of Directors has been appointed by the NSW Minister for Health to cover both agencies. The ACI will continue using the networks established by the GMCT to engage clinicians and the community (through the establishment of appropriate groups), NSW AHS and other public health organisations in identifying high quality, safe and cost-effective way of delivering services to patients.

The CEC has been in existence since 2004. Its major role is to promote best practice system for clinical quality and patient safety, including monitoring the state of quality and safety in the system, supporting AHS in the implementation of such systems, providing education and training for clinicians, consumers and managers and providing advice to the NSW Minister for Health regarding quality and safety issues in NSW.

The Institut for Medical Education and Training (IMET) was establised in 2005. Its role is to act as an advocate for medical training, support and coordinate the provision of post graduate training for doctors in NSW, support the roles of clinicians as teachers and trainers, provide advice regarding the distribution of medical training places in NSW and undertake research and evaluation of medical training systems. It offers clinical training programs in areas such as advanced cardiology, oncology, psychiatry, emergency medicine, radiology and paediatrics as well as non-clinical areas such as hospital skills,  leadership development and prevocational training.

Monitoring and evaluation

The performance of the agencies described above will be able to be monitored via publicly available reports. For example, the BHI is mandated to produce regular and timely reports on the performance of the NSW health system. The objective relating to these reports specifically mentions reports on waiting times, Emergency Department performance and hospital infection rates. However, the BHI is also likely to be judged by clinicians as well as the media and the general public in terms of the credibility of its reports - previously, government reports on these issues have been greeted with scepticism and the government has been accused of using the data selectively.

The CEC has set itself some broad performance goals. These are the extent to which its reports, data and methods are used and implemented (uptake), the extent to which demand for its leadership and clinical improvement programs increase (demand), the level of perceived satisfaction and respect for the CEC amongst clinical leaders and key decision makers (satisfaction) and the extent to which its influence extends across the system and it is regarded as a primary point of reference for quality and safety issues (influence). Since its inception, the CEC has gradually increased its influence and it is generally higly regarded within the NSW health system.

The other two agencies have not published such explicit aims and objectives nor agreed to their performance being judged in the same way as the BHI and the CEC. However, with the appointment of a common Board for the CEC and ACI, it is to be expected that their performance will be monitored and evaluated in a similar way.

Expected outcome

As the main thrust of these agencies is towards improving quality and safety, it is in this area that the most obvious improvement could be expected. However, if the BHI performs to expectations, its reports may also have an impact on equity (the fair distribution of services among the population of NSW) and it may also have an impact on efficiency (e.g., by influencing the uptake of cost-effective interventions and services and recommending the discontinuation of inefficient interventions etc).

The BHI in particular has the opportunity to have a wide-ranging influence on policy in NSW. It has as an exemplar, the NSW Bureau of Crime Statistics and Research (BOCSAR), whose Director is a member of the BHI Board of Directors. BOCSAR has been established for more than 10 years and, although funded by government and operationally part of the NSW Attorney General's Department, it has established a reputation for the production of high quality policy-relevant reports as well as one-off research projects and for the fearless and forthright performance of the Director in making all reports publicly available. BOCSAR is a very credible organisation in the eyes of the media, politicians and the crime and justice workforce. If the BHI can achieve the same level of credibility among its constituents, in particular, politicians and key clinical leaders and commentators, it will be an important means engaging with issues which are likely to impact on the performance of the health system in NSW.

Impact of this policy

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

As previously mentioned, the main thrust of the agencies is towards quality and safety and it is in this area that together, they are expected to have most influence. However, if the BHI in particular, meets expectations in this area, its reports may also have a positive influence on the level of equity and efficiency of the NSW health system.


Sources of Information

Stewart G, Dwyer J. Implementation of the Garling recommendations can offer real hope for rescuing the NSW public hospital system. Medical Journal of Australia 2009;190(2): 80-82


Reform formerly reported in

Public Hospital reform in NSW
Process Stages: Idea

Author/s and/or contributors to this survey

Marion Haas

Suggested citation for this online article

Marion Haas. "Continuing reform in NSW". Health Policy Monitor, April 2010. Available at