To the Editor: At school we were counselled that the most important criterion for passing examinations was to answer the actual questions asked and to avoid adding irrelevant material. The Garling report considered the organisation of New South Wales public hospitals, concluding:

Stewart and Dwyer’s commentary on Garling’s proposals2 ignores this core theme.

Garling recommends many significant changes that would directly affect doctors,1 such as:

• Within 6 months, NSW Health should redesign rostering systems and practices to ensure an appropriate number of senior clinicians are in hospitals for 16 hours a day, 7 days a week.

• NSW should require that all ward rounds occur in the early morning, be multidisciplinary, and that accurate and complete notes are taken and approved by the supervising doctor within 24 hours.

Rather than discussing the consequences, implications and implementation of Garling’s recommendations, Stewart and Dwyer air opinions on federal–state financial relationships, arguing that:

Stewart and Dwyer’s confused intent is evident in their criticism of federal funding provided to NSW in 2008 “to help divert patients who are not thought to need urgent care away from emergency departments and towards general practice services”. They believe this money “would do much more for emergency departments if it were used to open more beds and reduce access block”. However, later in their article they declare that “looking at a huge hospital system in isolation from other parts of the health care system is a somewhat artificial exercise”.2

Stewart and Dwyer’s views on the practical feasibility and day-to-day implications for doctors of Garling’s proposals would have been of interest. Broader health financing issues, including respective federal and state responsibilities, were not the focus of Garling’s report.

In reply: Coote is correct that the true benefits of the Garling recommendations lie in the details of implementation. This was not, however, our brief in our article;1 we were asked to identify the root causes of the current crisis in New South Wales public hospitals and to assess against these the potential for the Garling recommendations2 to pull the system “back from the brink”. From our list of 16 causes, we chose to give particular attention to the federal–state divide and the increasing disengagement of clinicians.

The reduction in federal funding to public hospitals over the past decade has been a major driver of clinician dissatisfaction and the widening gap between frontline workers and management, as is well captured in the Garling report.2 Reduced resources, including insufficient hospital beds, have driven the centralisation of authority and underpinned the bullying behaviour of some managers. A sizeable proportion of the much needed reforms recommended by Garling will be difficult to implement without the Australian Government providing its fair share of funding for the public hospital system.

In this context, a detailed implementation plan for Garling’s recommendations is essential — but, unfortunately, the recently released response from the NSW Government3 is very weak in this regard. Clinicians appear to have a long, hard struggle ahead to ensure that the road map to recovery laid down by Garling is followed by government and the bureaucracy, and that the changes needed are funded adequately.