08 June 2025

Hallucinations

In Ayinde v Haringey and Al-Haroun v Qatar  [2025] EWHC 1383 (Admin)  the Court offers a robust response to misuse of GenAI by litigants.

[3] The referrals arise out of the actual or suspected use by lawyers of generative artificial intelligence tools to produce written legal arguments or witness statements which are not then checked, so that false information (typically a fake citation or quotation) is put before the court. The facts of these cases raise concerns about the competence and conduct of the individual lawyers who have been referred to this court. They raise broader areas of concern however as to the adequacy of the training, supervision and regulation of those who practice before the courts, and as to the practical steps taken by those with responsibilities in those areas to ensure that lawyers who conduct litigation understand and comply with their professional and ethical responsibilities and their duties to the court. 

The use of artificial intelligence in court proceedings 

[4] Artificial intelligence is a powerful technology. It can be a useful tool in litigation, both civil and criminal. It is used for example to assist in the management of large disclosure exercises in the Business and Property Courts. A recent report into disclosure in cases of fraud before the criminal courts has recommended the creation of a cross-agency protocol covering the ethical and appropriate use of artificial intelligence in the analysis and disclosure of investigative material. Artificial intelligence is likely to have a continuing and important role in the conduct of litigation in the future. 

[5] This comes with an important proviso however. Artificial intelligence is a tool that carries with it risks as well as opportunities. Its use must take place therefore with an appropriate degree of oversight, and within a regulatory framework that ensures compliance with well-established professional and ethical standards if public confidence in the administration of justice is to be maintained. As Dias J said when referring the case of Al-Haroun to this court, the administration of justice depends upon the court being able to rely without question on the integrity of those who appear before it and on their professionalism in only making submissions which can properly be supported. 

[6] In the context of legal research, the risks of using artificial intelligence are now well known. Freely available generative artificial intelligence tools, trained on a large  language model such as ChatGPT are not capable of conducting reliable legal research. 

[7] Such tools can produce apparently coherent and plausible responses to prompts, but those coherent and plausible responses may turn out to be entirely incorrect. The responses may make confident assertions that are simply untrue. They may cite sources that do not exist. They may purport to quote passages from a genuine source that do not appear in that source.  Those who use artificial intelligence to conduct legal research notwithstanding these risks have a professional duty therefore to check the accuracy of such research by reference to authoritative sources, before using it in the course of their professional work (to advise clients or before a court, for example). 

[8] Authoritative sources include the Government’s database of legislation, the National Archives database of court judgments, the official Law Reports published by the Incorporated Council of Law Reporting for England and Wales and the databases of reputable legal publishers. This duty rests on lawyers who use artificial intelligence to conduct research themselves or rely on the work of others who have done so. This is no different from the responsibility of a lawyer who relies on the work of a trainee solicitor or a pupil barrister for example, or on information obtained from an internet search. 

[9] We would go further however. There are serious implications for the administration of justice and public confidence in the justice system if artificial intelligence is misused. In those circumstances, practical and effective measures must now be taken by those within the legal profession with individual leadership responsibilities (such as heads of chambers and managing partners) and by those with the responsibility for regulating the provision of legal services. Those measures must ensure that every individual currently providing legal services within this jurisdiction (whenever and wherever they were qualified to do so) understands and complies with their professional and ethical obligations and their duties to the court if using artificial intelligence. For the future, in Hamid hearings such as these, the profession can expect the court to inquire whether those leadership responsibilities have been fulfilled. 

Existing guidance 

[10] There is no shortage of professional guidance available about the limitations of artificial intelligence and the risks of using it for legal research. 

[11] The Bar Council published guidance in January 2024, headed: “Considerations when using ChatGPT and generative artificial intelligence software based on large language models.” [12] This document states (at paragraph 17):

“The ability of LLMs [large language models] to generate convincing but false content raises ethical concerns. Do not  therefore take such systems’ outputs on trust and certainly not at face value… It matters not that the misleading of the court may have been inadvertent, as it would still be considered incompetent and grossly negligent. Such conduct brings the profession into disrepute (a breach of Core Duty 5), which may well lead to disciplinary proceedings. Barristers may also face professional negligence, defamation and/or data protection claims through careless or inappropriate use of these systems. As set out above, the data used to ‘train’ generative LLMs may not be up to date; and can sometimes produce responses that are ambiguous, inaccurate or contaminated with inherent biases. Inherent bias may be invisible as it arises not only in the processing or training, but prior to that in the assembling of the training materials. LLMs may also generate responses which are out of context. For these reasons it is important for barristers to verify the output of AI LLM software and maintain proper procedures for checking the generative outputs.” 

[13] Similar warnings are contained in a document published by the Solicitors Regulation Authority, entitled “Risk Outlook report: the use of artificial intelligence in the legal market, 20 November 2023” . This says: “All computers can make mistakes. AI language models such as ChatGPT, however, can be more prone to this. That is because they work by anticipating the text that should follow the input they are given, but do not have a concept of ‘reality’. The result is known as ‘hallucination’, where a system produces highly plausible but incorrect results.” 

[14] We were also referred to a blog published by the Bar Standards Board on 8 October 2023 entitled “ChatGPT in the Courts: Safely and Effectively Navigating AI in Legal Practice”. It refers to Mata v Avianca Inc. an American case, summarised in the appendix to this judgment. The blog says:

“Two lawyers … used ChatGPT – a large language model AI – to identify relevant caselaw. One prompted the tool to draft a court submission, which they submitted verbatim on behalf of their client. However, unbeknownst to them, the AI-generated legal analysis was faulty and contained fictional citations… …the AI output was entirely fabricated, falsely attributing nonsensical opinions to real judges and embellished with further false citations and docket numbers held by actual cases irrelevant to the matter at hand…. AI, while a promising tool, is not a replacement for human responsibility and oversight. A lawyer is answerable for their  research, arguments, and representations under their core duties to the Court and to their client. These duties continue to hold true when utilising AI. This case demonstrates that it is more important than ever to understand the capabilities and limitations of a new technology to ensure that its contributions are genuine aids, not sources of misinformation.” 

[15] Guidance is also given to judges about the use of artificial intelligence. That guidance, first provided in December 2023 and updated in April 2025, is published on the judiciary’s website. Its contents are as relevant to the use of artificial intelligence by lawyers as they are to its use by the judiciary. It makes clear that it is necessary to uphold confidentiality and privacy by not entering into a public artificial intelligence tool any information that is not already in the public domain. It also makes clear that it is necessary to check any information that is provided by an artificial intelligence tool before it is used or relied upon. It further emphasises the need to be aware that artificial intelligence tools may make up fictitious cases, citations or quotes, or refer to legislation, articles or legal texts that do not exist, or provide incorrect or misleading information regarding the law or how it might apply, or make factual errors. 

[16] Importantly, the guidance says that: “All legal representatives are responsible for the material they put before the court/tribunal and have a professional obligation to ensure it is accurate and appropriate.” It warns about the risks of using generative artificial intelligence for legal research or legal analysis: “Legal research: AI tools are a poor way of conducting research to find new information you cannot verify independently. They may be useful as a way to be reminded of material you would recognise as correct. Legal analysis: the current public AI chatbots do not produce convincing analysis or reasoning.” 

Lawyers’ regulatory duties: Barristers 

[17] The Bar Standards Board Handbook  contains rules about how barristers must behave and work and the Code of Conduct for barristers. The Code of Conduct includes the ten Core Duties (CDs) which underpin the Bar Standards Board’s regulatory framework, and the rules which supplement those Core Duties. Compliance with the Core Duties and the rules is mandatory. The Code of Conduct also identifies the outcomes which compliance with the Core Duties and the rules are designed to achieve. 

[18] Materially in this context, barristers must observe their duty to the court in the administration of justice (CD 1). They must act with honesty and integrity (CD 3). They must not behave in a way which is likely to diminish the trust and confidence which the public places in the profession (CD 5). They must provide a competent standard of work to each client (CD 7). The outcomes which compliance with these Core Duties are designed to achieve include the following: the court is able to rely on information provided to it by those conducting litigation and by advocates who appear before it  (Outcome 1); the proper administration of justice is served (Outcome 2) and those who appear before the court understand clearly their duties to the court (Outcome 4). 

[19] Further, barristers are under a duty not to knowingly or recklessly mislead or attempt to mislead the court or anyone else (Rules C3.1 and C9.1). They are under a duty not to draft any document containing a contention which the author does not consider to be properly arguable (Rule C9.2.b) and they are under a duty to provide a competent standard of work (Rule C18). 

[20] The Bar Standards Board also publishes “The Professional Statement for Barristers” which sets out the knowledge, skills and attributes that all barristers must have on “day one” of practice. They include compliance with regulatory requirements (paragraph 1.16); an ability to draft court documents which are accurate, and skeleton arguments which present the relevant law and cite authorities in an appropriate manner (paragraphs 1.13 and 1.14); and an ability to recognise and operate within the limits of their competence (paragraph 1.18). 

[21] The Bar Qualification Manual requires pupil supervisors to provide pupils with a suitable training programme that enables them to meet the competences in the Professional Statement. It requires that pupil supervisors are appropriately trained. Documentation must be in place to evidence a pupil’s progress against the competencies set out in the Professional Statement. There are specific requirements in relation to evaluation, assessment and appraisal. A pupil must not be signed off as having completed the non-practising or practising period of pupillage unless the defined standards and competencies have been met. 

Lawyers’ regulatory duties: Solicitors 

[22] The position is materially similar for solicitors. The Code of Conduct of the Solicitors Regulation Authority (the SRA) describes the standards of professionalism that the SRA and the public expects of individuals authorised by the SRA to provide legal services. The SRA’s Rules of Conduct provide in part as follows. Solicitors are under a duty not to mislead the court or others including by omission (Rule 1.4). They are under a duty only to make assertions or put forward statements, representations or submissions to the court or others which are properly arguable (Rule 2.4). They are under a duty not to waste the court’s time (Rule 2.6). They are under a duty to draw the court’s attention to relevant cases and statutory provisions of which the lawyer is aware and which are likely to have a material effect on the outcome (Rule 2.7). They are under a duty to provide a competent service (Rule 3.2). Further, where work is conducted on a solicitor’s behalf by others, the solicitor remains accountable for the work (Rule 3.5). 

The court’s powers 

23. The court has a range of powers to ensure that lawyers comply with their duties to the court. Where those duties are not complied with, the court’s powers include public admonition of the lawyer, the imposition of a costs order, the imposition of a wasted costs order, striking out a case, referral to a regulator, the initiation of contempt proceedings, and referral to the police. 

24. The court’s response will depend on the particular facts of the case. Relevant factors are likely to include: (a) the importance of setting and enforcing proper standards; (b) the circumstances in which false material came to be put before the court; (c) whether an immediate, full and truthful explanation is given to the court and to other parties to the case; (d) the steps taken to mitigate the damage, if any; (e) the time and expense incurred by other parties to the case, and the resources used by the court in addressing the matter; (f) the impact on the underlying litigation and (g) the overriding objective of dealing with cases justly and at proportionate cost. 

Referral to the police for a criminal investigation 

25. In the most egregious cases, deliberately placing false material before the court with the intention of interfering with the administration of justice amounts to the common law criminal offence of perverting the course of justice, carrying a maximum sentence of life imprisonment. There has been one instance (not involving artificial intelligence) where a member of the Bar was imprisoned for 12 months for perverting the course of justice after deliberately causing a fake authority to be placed before the court by another person. He was subsequently disbarred: Bar Standards Board decision of 10 November 2008. Where there are reasonable grounds to suspect that a lawyer has committed a serious criminal offence, the appropriate response is likely to be that the court will refer the papers to the police to consider undertaking a criminal investigation. Such cases are likely to be extremely rare. 

Contempt of court 

26. Placing false material before the court with the intention that the court treats it as genuine may, depending on the person’s state of knowledge, amount to a contempt. That is because it deliberately interferes with the administration of justice. In R v Weisz ex p Hector Macdonald Ltd [1951] 2 KB 611 Lord Goddard CJ, Hilbery J and Devlin J held that an attempt to deceive a court by disguising the true nature of the claim by the indorsement on a writ (a claim for an unenforceable gambling debt dressed up as a claim for “an account stated”) amounted to a contempt. As to the requisite state of knowledge, mere negligence as to the falsity of the material is insufficient. There must be knowledge that it is false, or a lack of an honest belief that it is true: JSC BTA Bank v Ereschchenko [2013] EWCA Civ 829 per Lloyd LJ at [42], Newson-Smith v Al Zawawi [2017] EWHC 1876 (QB) per Whipple J at [12], Norman v Adler [2023] EWCA Civ 785 [2023] 1 WLR 4232 per Thirlwall LJ at [61]. 

27. Proceedings for contempt of court may be initiated under part 81 of the Civil Procedure Rules (CPR) by the court of its own motion, or by a Law Officer, or by anyone with a sufficient interest (such as a party in the case). The maximum term for which a contemnor, on one occasion, may be committed to prison is 2 years: Contempt of Court Act 1981, section 14(1). 

28. Where the court considers that a contempt of court may have been committed, it shall, on its own initiative, consider whether to initiate contempt proceedings: CPR 81.6. This is a two-stage process. The first, or threshold, stage is the assessment of whether a contempt may have been committed. The second is an evaluative judgement as to whether contempt proceedings should be initiated: R (Clearsprings Ready Homes Ltd)  v Swindon Magistrates’ Court [2024] EWHC 3245 (Admin) per Warby LJ and Dove J at [15]. 

Referral to regulator 

29. Where a lawyer places false citations before the court (whether because of the use of artificial intelligence without proper checks being made, or otherwise) that is likely to involve a breach of one or more of the regulatory requirements that we have set out above, and it is likely to be appropriate for the court to make a reference to the regulator. 

Strike out and costs sanctions 

30. A wasted costs order may be appropriate where the conditions in section 51(6) and (7) Senior Courts Act 1981 and paragraph 5.5 of CPR Practice Direction 46 are satisfied. It is necessary to show that the lawyer has acted improperly, unreasonably or negligently, that their conduct has caused a party to incur unnecessary costs and that it is just in all the circumstances to make an order. It is always necessary to apply the important procedural safeguards in CPR 46.8 (including providing the lawyer with a reasonable opportunity to make submissions or, if they prefer, to attend a hearing, before making the order). In principle, and subject to any explanation, we agree with Ritchie J that placing false material before the court with the intention of the court treating it as genuine amounts to improper and unreasonable and negligent conduct. Any lawyer who does this is at risk of the imposition of a wasted costs order. 

Admonishment 

31. Submissions were made to us as to the salutary effect of public admonishment, thereby mitigating any requirement to refer lawyers to their regulatory bodies or to deal with the matter as a contempt. We do not underestimate the impact of public criticism in a court judgment or indeed of appearing before a Divisional Court in circumstances such as these. However, the risks posed to the administration of justice if fake material is placed before a court are such that, save in exceptional circumstances, admonishment alone is unlikely to be a sufficient response. 

The Ayinde case 

The background 

32. The claimant, Mr Ayinde, brought proceedings for judicial review against the London Borough of Haringey (the defendant) in respect of its failure to provide interim accommodation pending a statutory review of a decision that he did not have a priority need for housing. Mr Ayinde was represented by the Haringey Law Centre. Mr Victor Amadigwe is a solicitor. He is the Chief Executive of the Haringey Law Centre. Ms Sunnelah Hussain is a paralegal working under his supervision. Ms Sarah Forey of counsel was instructed on behalf of the claimant. The grounds for judicial review were settled and signed by Ms Forey.  There is nothing new in this. The court has always taken steps to protect the integrity of its proceedings: Myers v Elman [1940] AC 282 per Lord Wright at 319. 

33. In those grounds, Ms Forey wrote: “The statutory duty under Section 188(3) of the Housing Act 1996 requires a local authority to provide interim accommodation when an individual has applied for a review of a homelessness decision.” 

34. This misstates the effect of section 188(3). Section 188(3) provides that: “…the authority may secure that accommodation is available for the applicant’s occupation pending a decision on review.” 

35. Ms Forey then wrote: “In R (on the application of El Gendi) v Camden LBC [2020] EWHC 2435 (Admin), the High Court emphasized that failing to provide interim accommodation during the review process undermines the protective purpose of the homelessness legislation. The court found that such a failure not only constitutes a breach of statutory duty but also creates unnecessary hardship for vulnerable individuals. The Respondent’s similar failure in the present case demonstrates procedural impropriety warranting judicial review.” 

36.  The case that is cited (El Gendi) does not exist. There is no case with that name, held by the National Archives, or anywhere else. The neutral citation number, [2020] EWHC 2435 (Admin), does exist, but it is the citation reference to a different case: R (Preservation and Promotion of the Arts Ltd) v Greater Manchester Magistrates’ Court [2020] EWHC 2435 (Admin). That case concerns a charity’s liability to pay business rates. It has nothing to do with duties under the Housing Act 1996. 

37. The grounds settled by Ms Forey included the following further passages:

“Moreover, in R (on the application of Ibrahim) v Waltham Forest LBC [2019] EWHC 1873 (Admin), the court quashed a local authority decision due to its failure to properly consider the applicant’s medical needs, underscoring the necessity for careful evaluation of such evidence in homelessness determinations. The Respondent’s failure to consider the Appellant’s medical conditions in their entirety, despite being presented with comprehensive medical documentation, renders their decision procedurally improper and irrational. … The Appellant’s situation mirrors the facts in R (on the application of H) v Ealing LBC [2021] EWHC 939 (Admin), where the court found the local authority’s failure to provide interim accommodation irrational in light of the applicant’s  vulnerability and the potential consequences of homelessness. The Respondent’s conduct in this case similarly lacks rational basis and demonstrates a failure to properly exercise its discretion. … The Respondent’s failure to provide a timely response and its refusal to offer interim accommodation have denied the Appellant a fair opportunity to secure his rights under the homelessness legislation. This breach is further highlighted in R (on the application of KN) v Barnet LBC [2020] EWHC 1066 (Admin), where the court held that procedural fairness includes timely decision-making and the provision of necessary accommodations during the review process. The Respondent’s failure to adhere to these principles constitutes a breach of the duty to act fairly. The Appellant’s case further aligns with the principles set out in R (on the application of Balogun) v LB Lambeth [2020] EWCA Civ 1442, where the Court of Appeal emphasized that local authorities must ensure fair treatment of applicants in the homelessness review process. The Respondent’s conduct in failing to provide interim accommodation or a timely decision breaches this standard of fairness.” 

38. 39. 40. The four further cases cited by Ms Forey do not exist either. We note too the Americanised spelling of “emphasized”, which contrasts with the English spelling of the same word by Ms Forey in correspondence; and further, the somewhat formulaic style of the prose. On 4 February 2025, the solicitor for the defendant, Mr Greenberg, wrote to Mr Amadigwe (copied to Ms Hussain) and said that they could not find five of the cases set out in the grounds. On the same day, Ms Hussain emailed Ms Forey and asked her to provide copies of the five cases. Mr Amadigwe also wrote to Ms Forey the same day and asked her to provide copies of the five cases. Ms Hussain repeated the request on a call with Ms Forey the next day. 7 Mr Greenberg sent a second letter to Mr Amadigwe (copied to Ms Hussain) under cover of an email dated 18 February 2025. In that letter, Mr Greenberg said that they had conducted searches for the five cases and had also instructed counsel to assist. He explained the outcome of those searches. The cases cited did not exist. He drew attention to Olsen v Finansiel Stabilitet A/S [2025] EWHC 42 (KB) (a case summarised in the appendix) and pointed out “the severity of seeking to rely on cases that do not exist.” Mr Greenberg also pointed out that the grounds of claim misstated the effect of section 188(3) of the Housing Act 1996. He said that the defendant would be making a wasted costs application against Haringey Law Centre and/or Ms Forey.  We know all of this because the claimant, Mr Ayinde, has waived legal professional privilege.  

41. 42. Ms Hussain forwarded Mr Greenberg’s second letter to Ms Forey on the same day (18 February). Ms Hussain asked Ms Forey once again for copies of the five cases and for a response she could send to the defendant. On 22 February, Ms Hussain called Ms Forey who said that she was going to meet with a colleague to provide the cases and that she would send them shortly. On 4 March 2025 Ms Forey sent Ms Hussain a draft response to be sent to the defendant. In a call with Ms Hussain after circulating the draft response, Ms Forey said that she was still learning, and asked if Ms Hussain or Mr Amadigwe could review the draft response. Ms Hussain forwarded the draft response to Mr Amadigwe who responded “You can send it, but change ‘me’ to ‘we’ and ‘I’ to ‘we’”. Ms Hussain made those changes (and no other changes) and on 5 March sent an email to the defendant. This was in terms of Ms Forey’s draft, with the changes ‘me’ to ‘we’ and ‘I’ to ‘we’ only. The email said:

“We regret to say that we still do not see the point you are making by correlating any errors in citations to the issues addressed in the request for judicial review in this matter. Admittedly, there could be some concessions from our side in relation to any erroneous citation in the grounds, which are easily explained and can be corrected on the record if it were immediately necessary to do so. What you have not done is to refute the veracity of the points and legal arguments that prevailed against your position and any failures of your client to measure up to its obligations under the 1996 Act. Indeed, it appears that you have not only taken any and all of our paraphrases and references out of context, but that you have also misinterpreted the context, scope and authority of section 188(3) of the said Act. We do not think that our duty of care should go so far as to provide legal interpretation of the laws for your benefit, but we hasten to say that section 188(3) provides for discretionary action in relation to section 202 and so long as that duty falls outside section 189B(2). It is not a broad brushed discretion that results from the ‘May’ in that subsection. We therefore do not quite grasp in what context you say: Haringey have a discretion. There is no obligation. So let us agree that the citation errors can be corrected on the record ahead of our April hearing. Apart from adding our deepest apologies, we do not consider that we are obliged to explain anything further to you directly. You may better serve your organisation by giving attention not to the normative discoveries you have made, but whether you can locate the authorities in support of the points raised, which points you are clearly in agreement with, as demonstrated both by conduct in offering the necessary relief to our client and acting in accordance with the mandate of your client.  We hope that you are not raising these errors as technicalities to avoid undertaking really serious legal research. Treating with citations is a totally separate matter for which we will take full responsibility. It appears to us improper to barter our client's legal position for cosmetic errors as serious as those can be for us as legal practitioners. For the foregoing reasons alone, your claim for costs and the costs of your letters are rejected as without foundation. Your response or arguments in defence cannot rely on errors in citation to prevail but on the evidential and meritorious basis of your points. We will prepare the bundle index and send this to you shortly for your consideration.” 

43. On 7 March 2025, the defendant made an application for a wasted costs order against Haringey Law Centre and Ms Forey. This was made on the grounds that they had cited five fake cases, they had failed to produce copies of the cases when requested to do so, and they had misstated the effect of section 188(3) of the Housing Act 1996 throughout the grounds. 

The hearing before Ritchie J 

44. 45. 46. On 3 April 2025, the wasted costs application was heard by Ritchie J. By that stage, the defendant had provided accommodation for the claimant and the underlying claim for judicial review had been resolved. At the hearing, Ms Forey did not formally give evidence, but she did give her explanation for what had happened. According to the judgment of Ritchie J ([2025] EWHC 1040 (Admin)), she said that she kept a box of copies of cases, and she kept a paper and digital list of cases with their ratios. She said that she had “dragged and dropped” the reference to El Gendi from that list into the grounds for judicial review. At [53], Ritchie J rejected this explanation:

“I do not understand that explanation or how it hangs together. If she herself had put together, through research, a list of cases and they were photocopied in a box, this case could not have been one of them because it does not exist. Secondly, if she had written a table of cases and the ratio of each case, this could not have been in that table because it does not exist. Thirdly, if she had dropped it into an important court pleading, for which she bears professional responsibility because she puts her name on it, she should not have been making the submission to a High Court Judge that this case actually ever existed, because it does not exist. I find as a fact that the case did not exist. I reject Miss Forey’s explanation.” 

47. After describing the email of 5 March 2025 as “remarkable”, Ritchie J added, at [46]:

“I do not consider that it was fair or reasonable to say that the erroneous citations could easily be explained and then to refuse to explain them. Nor do I consider it was professional, reasonable or fair to say it was not necessary to explain the citations. The assertion that they agreed to correct the citations before April never came true, for they never did. The assertion that no further explanation or obligation to provide an explanation was necessary or arose is, in my judgment, quite wrong. Worst of all, the assertion that the citations are merely cosmetic errors is a grossly unprofessional categorisation.” 

48. Ritchie J found, at [64] to [65], that the behaviour of Ms Forey and the Haringey Law Centre had been improper and unreasonable and negligent:

“64. …It is wholly improper to put fake cases in a pleading. It was unreasonable, when it was pointed out, to say that these fake cases were “minor citation errors” or to use the phrase of the solicitors, “Cosmetic errors”. I should say it is the responsibility of the legal team, including the solicitors, to see that the statement of facts and grounds are correct. They should have been shocked when they were told that the citations did not exist. Ms Forey should have reported herself to the Bar Council. I think also that the solicitors should have reported themselves to the Solicitors Regulation Authority. I consider that providing a fake description of five fake cases, including a Court of Appeal case, qualifies quite clearly as professional misconduct. 

65. On the balance of probabilities, I consider that it would have been negligent for this barrister, if she used AI and did not check it, to put that text into her pleading. However, I am not in a position to determine whether she did use AI. I find as a fact that Ms Forey intentionally put these cases into her statement of facts and grounds, not caring whether they existed or not, because she had got them from a source which I do not know but certainly was not photocopying cases, putting them in a box and tabulating them, and certainly not from any law report. I do not accept that it is possible to photocopy a non-existent case and tabulate it. Improper and unreasonable conduct are finding[s] about which I am sure. In relation to negligence I am unsure but I consider that it would fall into that category if Ms Forey obtained the text from AI and failed to check it.” 

49. Ritchie J found that this conduct caused the defendant loss and that the justice of the case required him to make a wasted costs order. He ordered Ms Forey and the Haringey Law Centre each to pay £2,000 to the defendant. He also required the matter to be referred to the Bar Standards Board and the Solicitors Regulation Authority. On 9 May 2025, Ritchie J made an order referring the case to the Hamid judge, Linden J. 

50. 51. 52. Ms Forey, Ms Hussain and Mr Amadigwe (who has supervisory responsibilities in respect of Ms Hussain) have each filed a witness statement. Ms Forey filed a second witness statement on the evening before this Hamid hearing. Ms Forey Ms Forey sets out in her first statement her education and background. We have taken that into account, and we do not consider it necessary to recite it in this judgment. Ms Forey was called to the Bar in 2021 and started her pupillage in September 2023. At the time of the hearing before Ritchie J she was still a pupil barrister. She says that she had received little formal supervision during her first six months pupillage. She does not recall attending court with a member of chambers in relation to a claim for judicial review in a homelessness case. She says that during her second six months pupillage she had an extremely busy practice in her own right. She did not receive any supervision. None of her written work was checked. She says that at the time of the application for wasted costs before Ritchie J she was extremely upset. In written and oral submissions advanced on her behalf, it was said, notwithstanding the terms of the defendant’s letter of 18 February, that she was “blindsided”. She says she did not manage properly to explain to Ritchie J how she worked, and that it was not correct that she “kept a box of copies of cases” and that these were “photocopied in a box”. She does not think she said this. She says she has never kept hard copies of cases in a box; all her research is conducted electronically. The list of cases that she put together with their ratios and principles was derived from electronic sources. She says that she has since conducted research “into the wrongly cited cases”:

“I… was able to locate a case R (Kelly and ORS) v Birmingham [2009] EWHC 3240 (Admin). Foolishly I did not take a copy of the Judgment to Court I can see from the similarities to what I had wrongly described as being the case of R (on the application of El Gendi) v Camden London Borough Council EWHC 2435 (Admin), that this would have been the case that I had been referring to in the Skeleton Argument, but with a wrongful citation. I realise now that this case did not in any event relate to s188(3) of the Housing Act but to s188(1).” 

53. She denies using artificial intelligence tools to assist her with legal research and says that she is aware that artificial intelligence “is not a reliable source.” She says that once the issue was raised by Haringey Council, she drafted the email that was then sent by Haringey Law Centre on 5 March 2025. 

54. Ms Forey fully accepts that she acted negligently, and she apologises to the court for that. In her first witness statement she denied that she acted improperly or unreasonably and denied that she was seeking or intending to mislead the court. During the course of the hearing before us, she maintained that position save that she accepted that she had acted unreasonably. 

55. 56. 57. 58. 59. Ms Forey has informed us of a separate incident where she put false material before a court. That was a case before the County Court where she was, again, instructed by the Haringey Law Centre. The hearing was on 10 April 2025, before His Honour Judge Andrew Holmes (the judge). Ms Forey was unable to conduct the hearing and another counsel (from a different set of chambers) was instructed in her stead. That counsel drew attention to the fact that the application before the judge contained false material: specifically the grounds of appeal and the skeleton argument settled by Ms Forey contained references to a number of cases that do not exist. On the day of that hearing, the judge wrote to Ms Forey’s Head of Chambers. He raised the question of a referral to the Bar Standards Board. In the event, however, the judge was satisfied with assurances given by Ms Forey and her Head of Chambers and so did not refer the case to the regulator. Ms Forey says that on 22 April 2025 a senior member of her chambers advised her to delete her list of cases/research and instead to use a recognised legal search engine. She accepted that advice. It follows that she has not been able to put her list of cases before us, or explain for that matter where the list of cases and citations derived from. In her second witness statement, Ms Forey says that when she drafted the grounds she “may also have carried out searches on Google or Safari” and that she may have taken account of artificial intelligence generated summaries of the results (without realising what they were). She also says that on 4 March 2025 she told Ms Hussain that she had been unable to find the case reports. Ms Hussain and Mr Amadigwe Ms Hussain and Mr Amadigwe have also each apologised to the court. Mr Amadigwe explains that the Haringey Law Centre is a charitable organisation that operates with minimal public funding. It has a limited workforce, but a very significant volume of cases. Ms Hussain is a paralegal. She is not a qualified solicitor.8 Mr Amadigwe says that Haringey Law Centre relies heavily on the expertise of specialist counsel. It has not been its practice to verify the accuracy of case citations or to check the genuineness of authorities relied on by counsel. It had not occurred to either Ms Hussain or Mr Amadigwe that counsel would rely on authorities that do not exist. When Haringey Council raised concerns about the five authorities, Ms Hussain and Mr Amadigwe wrote to Ms Forey and asked her to provide copies of the cases. Ms Forey did not do so, but she did provide the wording for the email that Ms Hussain sent on 5 March 2025. In the light of that wording, Ms Hussain and Mr Amadigwe did not appreciate that the five cases that had been cited were fake – they wrongly thought that there were minor errors in the citations which would be corrected before the court. Ms Hussain denies that Ms Forey told her that she had been unable to find the cases. It was only at the hearing before Ritchie J that they realised that the authorities did not exist. Mr Amadigwe has now given instructions to all his colleagues within Haringey Law Centre that all citations referred to by any counsel must be checked. 8 A paralegal is not, generally, a solicitor or barrister and is thus not subject to the same regulatory requirements. They can only do certain work under the direct supervision of a regulated lawyer. 

Submissions 

60. Helen Evans KC, for Ms Forey, submits that the threshold for the initiation of contempt proceedings is not met. That is because (a) Ms Forey did not know the citations were false; (b) the errors did not make any difference to the outcome; (c) Ms Forey was very inexperienced and had a difficult working and home environment; (d) she did not appreciate the gravity of what had gone wrong and (e) she now realises the seriousness of her mistakes, apologises for them and has shown insight. 

61. Andrew Edge, for Mr Amadigwe, Ms Hussain and the Haringey Law Centre, submits that Ms Forey bears the primary responsibility for what occurred. He accepts that Mr Amadigwe should have appreciated the seriousness of the matter once it was raised by the local authority, and that inadequate steps were taken in response. He stresses that this must be viewed in the context of an overstretched charity with limited resources. He submits that the threshold for initiating contempt proceedings has not been met and that, in the light of the steps that are now being taken, it is not necessary or proportionate to refer Mr Amadigwe to the regulator. In respect of Ms Hussain, he submits that she was blameless. She was a paralegal working with instructed counsel under the supervision of Mr Amadigwe, a solicitor, and had acted in accordance with his directions, including when liaising with counsel. 

62. In the light of Ms Forey’s evidence in her witness statement as to her training, her chambers were informed by the court of this Hamid hearing, provided with the hearing bundle, and invited to attend (or be represented at) the hearing on the basis that the court might wish to consider the extent to which Ms Forey had been properly supervised. Following the hearing, the court received an email communication from the Chambers Director at Ms Forey’s chambers, Mr Forjour. This disputes Ms Forey’s account that she received inadequate supervision. We arranged for a copy of the email to be sent to Ms Evans and Mr Edge, but without seeking further evidence or submissions. 

Our conclusions 

63. In our judgment, Ms Hussain is not at fault in any way. She acted appropriately throughout. She referred all matters to Mr Amadigwe, who was supervising her, or to Ms Forey, who was instructed counsel and she acted entirely in accordance with what she was told to do by Mr Amadigwe. Ritchie J could not have known this, because at the time of the hearing before him privilege had not been waived and, on the face of the documents, Ms Hussain had written the email of 5 March 2025. We have the benefit of the contemporaneous attendance notes and internal emails which make the position clear. 

64. As for Ms Forey, as we have said, Ritchie J did not accept her account given at the hearing on 3 April as to how she had come to rely on false information (the fake cases) and materially misstate the law. As to the status of those findings in the context of potential contempt proceedings, Ms Evans drew our attention to Frain v Reeves [2023] EWHC 73 (Ch) per Joanna Smith J at [33], and Bailey v Bailey [2022] EWFC 5 per Peel J at [10] to [17]. Subject to admissibility (which Ms Evans conceded), it would be for the court to decide how much weight to attribute to those findings but nothing derogates from the long established principle that contempt must be proved to the criminal standard. 

65. 66. 67. 68. 69. Since then, privilege has been waived, the attendance notes and the communications between Ms Forey, Ms Hussain and Mr Amadigwe have been disclosed, and Ms Forey has provided two witness statements. Ms Forey now accepts that she is at fault to a degree, but maintains her denial that she used generative artificial intelligence tools when preparing her list of cases or the grounds for judicial review. She says that her list of cases was compiled from various identified websites. It is not, however, suggested that any of the fake cases that she cited appeared, or have ever appeared, on those websites. In her most recent statement, she says that she would make general internet searches, but is now unable to identify any source for the fake cases anywhere on the internet (Ms Evans told us her instructing solicitors had conducted an internet search but could find no reference to those fake citations save to the reference to them in the judgment of Ritchie J and the subsequent reporting of that judgment). Ms Forey says in her second witness statement that some internet searches (on Google for example) provide a summary response which is produced by a generative artificial intelligence tool. We were not, however, provided with any evidence to support a contention (which in any event, was not directly advanced) that the fake cases that Ms Forey put before the court in Mr Ayinde’s claim for judicial review might have emerged in that way. Ms Forey refuses to accept that her conduct was improper. She says that the underlying legal principles for which the cases were cited were sound, and that there are other authorities that could be cited to support those principles. She went as far as to state that these other authorities were the authorities that she “intended” to cite (a proposition which, if taken literally, is not credible). An analogy was drawn with the mislabelling of a tin where the tin, in fact, contains the correct product. In our judgment, this entirely misses the point and shows a worrying lack of insight. We do not accept that a lack of access to textbooks or electronic subscription services within chambers, if that is the position, provides anything more than marginal mitigation. Ms Forey could have checked the cases she cited by searching the National Archives’ caselaw website or by going to the law library of her Inn of Court. We regret to say that she has not provided to the court a coherent explanation for what happened. On the material before us, there seem to be two possible scenarios. One is that Ms Forey deliberately included fake citations in her written work. That would be a clear contempt of court. The other is that she did use generative artificial intelligence tools to produce her list of cases and/or to draft parts of the grounds of claim. In that event, her denial (in a witness statement supported by a statement of truth) is untruthful. Again, that would amount to a contempt. In all the circumstances, we consider that the threshold for initiating contempt proceedings is met. However, we have decided not to initiate contempt proceedings or to refer the case to the Law Officers. First, there are a number of factual issues which could not easily be determined in the course of summary proceedings for contempt. Secondly, there are questions raised as to potential failings on the part of those who had responsibility for training Ms Forey, for supervising her, for “signing off” her pupillage, for allocating work to her, and for marketing her services. Those could not be addressed in contempt proceedings brought against Ms Forey alone. Thirdly, Ms Forey has already been criticised in a public judgment; she has been referred to the regulator and her conduct   

70. 71. 72. will be the subject of an investigation by her regulator. Fourthly, she is an extremely junior lawyer who was apparently operating outside her level of competence and in a difficult home and work context. Fifthly, our overarching concern is to ensure that lawyers clearly understand the consequences (if they did not before) of using artificial intelligence for legal research without checking that research by reference to authoritative sources. This court’s decision not to initiate contempt proceedings in respect of Ms Forey is not a precedent. Lawyers who do not comply with their professional obligations in this respect risk severe sanction. Though Ms Forey has now been referred to her professional regulator by Ritchie J and has also self-referred, we have decided that the court should also refer her to the regulator. We consider that the following matters, at least, require further consideration by the regulator: The circumstances in which Ms Forey came to put false cases before HHJ Holmes and before Ritchie J. 

The truthfulness of the account given by Ms Forey to Ritchie J and in her witness statements. 

The circumstances in which her list of cases came to be deleted, and whether it can now be retrieved. Whether those responsible for supervising Ms Forey’s pupillage in chambers complied with the relevant regulatory requirements in respect of her supervision, the way in which work was allocated to her, and her competence to undertake the level of work that she was doing. So far as Mr Amadigwe and the Haringey Law Centre are concerned, we accept that they are an overstretched charity providing an important service to vulnerable members of society with limited resources. It could be said however, that in those circumstances, it is all the more important that professional standards are maintained, and they instruct those who adhere to them. Moreover, so far as this particular case is concerned, it was conducted with the benefit of a legal aid certificate which provided funding for both solicitors and counsel. There is no basis however to suspect that Mr Amadigwe deliberately caused false material to be put before the court. There is no question of initiating contempt proceedings in respect of him. He had, however, been put on notice as to what had happened: the letter from the solicitor for the local authority was clear. The steps taken by Mr Amadigwe in response were inadequate. We refer the matter to the Solicitors Regulation Authority. We consider the following matters at least requires further consideration by the regulator: the steps taken by Mr Amadigwe in response to the correspondence from Mr Greenberg; and the steps he took to satisfy himself that Ms Forey had sufficient experience or was competent to undertake the work she had been instructed by Haringey Law Centre to do. The Al-Haroun case The background 

73. The claimant, Mr Al-Haroun, seeks damages of £89.4 million for alleged breaches of a financing agreement. His solicitor is Abid Hussain of Primus Solicitors. The defendants are the Qatar National Bank and QNB Capital. The defendants filed applications to dispute the court’s jurisdiction and to strike out the claim or to enter summary judgment.  Directions were given for the hearing of those applications. In April 2025, Dias J extended the time for the defendants to file and serve evidence in relation to the applications. The claimant applied to set aside that order. He provided a witness statement, and he also relied on a witness statement from his solicitor, Abid Hussain. The parties agreed that the application did not require a hearing. On 9 May 2025, Dias J dismissed the application. She referred the papers for consideration by the Hamid judge. She gave the following reasons:

“The court is deeply troubled and concerned by the fact that in the course of correspondence with the court and in the witness statements of both Mr Al-Haroun and Mr Hussain, reliance is placed on numerous authorities, many of which appear to be either completely fictitious or which, if they exist at all, do not contain the passages supposedly quoted from them, or do not support the propositions for which they are cited: see the attached schedule of references prepared by one of the court’s judicial assistants. It goes without saying that this is a matter of the utmost seriousness. Primus Solicitors are regulated by the SRA and Mr Hussain is accordingly an officer of the court. As such, both he and they are under a duty not to mislead or attempt to mislead the court, either by their own acts or omissions or by allowing or being complicit in the act or omissions of their client. The administration of justice depends upon the court being able to rely without question on the integrity of those who appear before it and on their professionalism in only making submissions which can properly be supported. Putting before the court supposed “authorities” which do not in fact exist, or which are not authority for the propositions relied upon is prima facie only explicable as either a conscious attempt to mislead or an unacceptable failure to exercise reasonable diligence to verify the material relied upon. For these reasons, the court considers it appropriate to refer the case for further consideration under the Hamid jurisdiction, pending which all questions of costs are reserved.” 

74. The schedule of references referred to by Dias J lists forty five citations that had been put before the court. In eighteen instances, the case cited does not exist. In respect of those cases that did exist, in many instances they did not contain the quotations that were attributed to them, did not support the propositions for which they were cited, and did not have any relevance to the subject matter of the application. In the judicial assistant’s pithy conclusion “The vast majority of the authorities are made up or misunderstood.” 

Evidence and submissions 

75. 76. 77. 78. Mr Al-Haroun, and Mr Hussain, have each filed a witness statement. Mr Al-Haroun accepts responsibility for the inclusion of inaccurate and fictitious material in the witness statement that he filed with the court. He says that the citations were generated using publicly available artificial intelligence tools, legal search engines and online sources. He had complete (but he accepts misplaced) confidence in the authenticity of the material that he put before the court. He stresses that he did not intend to misstate the law or to cause confusion to the court or the defendants or his own legal representatives. He offers a sincere apology to the court and to the defendants and to his own legal representatives. He seeks to absolve his solicitor from any responsibility. For his part, Mr Hussain accepts that his witness statement contained citations of non- existent authorities. He says that he relied on legal research that Mr Al-Haroun had conducted, without independently verifying the authorities. He accepts this was wrong. He says that he has never before been called before a conduct hearing and has never previously been reported to the Solicitors Regulation Authority. He has reported himself, and he will send them a copy of his witness statement. He stresses that he had no intention to mislead the court. In the light of what has happened he has removed himself “from all litigated matters” and he will undertake a review of best practices regarding legal drafting and the ethical duties of solicitors in the conduct of litigation, and he will attend further continuous professional development training. He gives an assurance that this will never happen again, and he offers an unreserved apology to the court. David Lonsdale, on behalf of Primus Solicitors and Mr Hussain, accepts that their conduct “could not be worse”, that it is “very very bad indeed”, and that “the very last thing any solicitor should do is to rely on the research of a lay client”. He says that Primus Solicitors and Mr Hussain were each “horrified” and that Mr Hussain could not reproach himself more for what had happened. Mr Lonsdale draws attention to two particular points in mitigation of what went wrong. First, it is obvious that Mr Hussain had no idea that the citations and quotations were fake. Secondly, the documents had been provided to counsel who had advised against making the application but who had not drawn attention to the fact that the citations and quotations were fake. In all the circumstances (and particularly in the light of Mr Hussain’s self-referral to the Solicitors Regulatory Authority) he submits that no further action is required. 

Our conclusions 

79. We note what Mr Al-Haroun says, his candour, his apology and his acceptance of responsibility. We accept that he did not have any intention to mislead the court or anyone else. However, the focus of our consideration of these cases is on the conduct of the lawyers rather than the litigants. Mr Al-Haroun’s errors do not absolve his legal representatives of responsibility. On the contrary, as Mr Lonsdale recognised, it is extraordinary that the lawyer was relying on the client for the accuracy of their legal research, rather than the other way around. 

80. As to counsel who reviewed the material that had been drafted by Mr Al-Haroun, he did not put the material before the court. Having formed an adverse view as to the merits  of the application, and having communicated that view, and having apparently played no further part in the matter, there is scope for argument as to whether he should have advised on the accuracy of Mr Al-Haroun’s various citations and quotations. 

[81] We were not shown any contemporaneous note of the advice given by counsel (indeed we were told in submissions that no attendance note had been taken of it), and there appears to be a factual dispute as to the precise advice given. In all the circumstances, we do not consider that the threshold for a court referral to the Bar Standards Board is met. That does not, of course, prevent Mr Hussain from making a complaint, or from raising the matter in explanation or mitigation before the regulator. As to Mr Hussain, and Primus Solicitors, there was a lamentable failure to comply with the basic requirement to check the accuracy of material that is put before the court. A lawyer is not entitled to rely on their lay client for the accuracy of citations of authority or quotations that are contained in documents put before the court by the lawyer. It is the lawyer’s professional responsibility to ensure the accuracy of such material. We are satisfied that Mr Hussain did not realise the true position. It is striking that one of the fake authorities that was cited to Dias J was a decision that was attributed to Dias J. If this had been a deliberate attempt to mislead the court, it was always going to fail. The threshold for the initiation of contempt proceedings is, accordingly, not met. Mr Hussain has referred himself to the Solicitors Regulation Authority. We will also make a referral. 

Further steps 

82. We have set out some of the guidance that has been promulgated by the regulatory bodies. These Hamid cases show that promulgating such guidance on its own is insufficient to address the misuse of artificial intelligence. More needs to be done to ensure that the guidance is followed and lawyers comply with their duties to the court. A copy of this judgment will be sent to the Bar Council and the Law Society, and to the Council of the Inns of Court. We invite them to consider as a matter of urgency what further steps they should now take in the light of this judgment. A 

Appendix 

83. There have been many instances, in countries around the world, of material being put before a court that is generated by an artificial intelligence tool, but which is erroneous. The following selection (many more examples could be given) show something of the extent of the problem. England and Wales 

84. In a case before the First-tier tribunal, SW Harber v Commissions for His Majesty’s Revenue and Customs [2023] UKFTT 1007 (TC), the appellant had disposed of a property and failed to notify her liability to capital gains tax. She was issued with a penalty. She appealed. She put before the tribunal the names, dates and summaries of what were said to be nine First-tier Tribunal decisions which supported her case. These had been provided to her by “a friend in a solicitor’s office” who she had asked to assist with her appeal. None of the authorities were genuine. At [18] to [19] the Tribunal said:

“18. The Tribunal told the parties that we… had looked at the FTT website and other legal websites and had… been unable to find any of the cases in the Response. We asked Mrs Harber if the cases had been generated by an AI system, such as ChatGPT. Mrs Harber said this was “possible”, but moved quickly on to say that she couldn’t see that it made any difference, as there must have been other FTT cases in which the Tribunal had decided that a person’s ignorance of the law and/or mental health condition provided a reasonable excuse. 

19. Mrs Harber then asked how the Tribunal could be confident that the cases relied on by HMRC and included in the Authorities Bundle were genuine. The Tribunal pointed out that HMRC had provided the full copy of each of those judgments and not simply a summary, and the judgments were also available on publicly accessible websites such as that of the FTT and the British and Irish Legal Information Institute (“BAILLI”). Mrs Harber had been unaware of those websites.” 

85. In Olsen v Finansiel Stabilitet A/S [2025] EWHC 42 (KB) the appellants (who were acting in person) appealed against a decision to register in the High Court a judgment given by a Danish court for just over €5.8 million, plus about 1.25 million Danish Kroner. The appellants relied on a case summary of an authority, with a neutral citation indicating it was a decision of the Court of Appeal, which did not exist. Kerr J said the summary was “written in a style that made me think the author was a lawyer familiar with the Judgments Regulation, but whose first language is not English.” The appellants explained that they had been assisted by their “extensive legal network” who had provided the case summary. They stressed that the “key legal principles underpinning the citation remain well-supported by established case law and statutory interpretation.” Kerr J said, at [113]:

“I have narrowly and somewhat reluctantly come to the conclusion that I should not cause a summons for contempt of court to be issued to the appellants under CPR rule 81.6. I do not think it likely that a judge (whether myself or another judge) could be sure, to the criminal standard of proof, that the appellants knew the case summary was a fake. They may have known but they could not be compelled to answer questions about the identity of the person who supplied it.” 

86. In Zzaman v Commissioners for His Majesty’s Revenue and Customs [2025] UKFTT 00539 (TC) the appellant, who was acting in person, relied on artificial intelligence to help him produce his written arguments. The resulting document included references to a number of genuine cases, but the Tribunal found (at [19]) that none of the cases that had been cited “materially assisted” and that (at [29]) they did not “provide authority for the propositions that were advanced.” The Tribunal said: 

“This highlights the dangers of reliance on AI tools without human checks to confirm that assertions the tool is generating are accurate. Litigants using AI tools for legal research would be well advised to check carefully what it produces and any authorities that are referenced. These tools may not have access to the authorities required to produce an accurate answer, may not fully “understand” what is being asked or may miss relevant materials. When this happens, AI tools may produce an answer that seems plausible, but which is not accurate. These tools may create fake authorities (as seemed to be the case in Harber) or use the names of cases to which it does have access but which are not relevant to the answer being sought (as was the case in this appeal). There is no reliable way to stop this, but the dangers can be reduced by the use of clear prompts, asking the tool to cite specific paragraphs of authorities (so that it is easy to check if the paragraphs support the argument advanced), checking to see the tool has access to live internet data, asking the tool not to provide an answer if it is not sure and asking the tool for information on the shortcomings of the case being advanced. Otherwise there is a significant danger that the use of an AI tool may lead to material being put before the court that serves no one well, since it raises the expectations of litigants and wastes the court’s time and that of opposing parties.” 

87. We agree with the Tribunal as to the dangers and the need for caution. We do not, however, consider that the risks are materially reduced by “asking the tool not to provide an answer if it is not sure and asking the tool for information on the shortcomings of the case being advanced.” The critical safeguard is to check any output by reference to an authoritative source. 

88. Bandla v Solicitors Regulation Authority [2025] EWHC 1167 (Admin) was decided just a week before the hearing in these cases. The appellant appealed against a decision of the Solicitors Disciplinary Tribunal to strike him off the roll of solicitors. The appellant cited twenty five cases which did not exist. He denied that he had used artificial intelligence, but he accepted that he had not checked the citations. At [53] Fordham J said:

 

“I asked the Appellant why, in the light of this citation of non- existent authorities, the Court should not of its own motion strike out the grounds of appeal in this case, as being an abuse of the process of the Court. His answer was as follows. He claimed that the substance of the points which were being put forward in the grounds of appeal were sound, even if the authority which was being cited for those points did not exist. He was saying, on that basis, that the citation of non-existent (fake) authorities would not be a sufficient basis to concern the Court, at least to the extent of taking that course. I was wholly unpersuaded by that answer. In my judgment, the Court needs to take decisive action to protect the integrity of its processes against any citation of fake authority. There have been multiple examples of fake authorities cited by the Appellant to the Court, in these proceedings. They are non-existent cases. Here, moreover, they have been put forward by someone who was previously a practising solicitor. The citations were included, and maintained, in formal documents before the Court. They were never withdrawn. They were never explained. That, notwithstanding that they were pointed out by the SRA, well ahead of this hearing. This, in my judgment, constitutes a set of circumstances in which I should exercise – and so I will exercise – the power of the Court to strike out the grounds of appeal in this case as an abuse of process.”

United States of America 

89. In Mata v Avianca Inc Case No. 22-cv-1461 (PKC), 2o23 WL 4114965 (SDNY 22 June 2023), a lawyer produced material before the United States District Court for the Southern District of New York which had been generated by ChatGPT. The opposing lawyer, and the court, were unable to find seven of the cases that had been cited. The court made an order requiring the cases to be produced. The lawyer then provided what purported to be excerpts from the cases. Rather than trying to locate the cases, the lawyer had simply asked ChatGPT to summarise the cases it had cited. It was apparent that, as Judge Castel put it, these showed “stylistic and reasoning flaws that do not generally appear in decisions issued by United States Courts of Appeals. Its legal analysis is gibberish.” Judge Castel explained some of the consequences of citing non- existent authorities: “Many harms flow from the submission of fake opinions. The opposing party wastes time and money in exposing the deception. The Court’s time is taken from other important endeavors. The client may be deprived of arguments based on authentic judicial precedents. There is potential harm to the reputation of judges and courts whose names are falsely invoked as authors of the bogus opinions and to the reputation of a party attributed with fictional conduct. It promotes cynicism about the legal profession and the American judicial system. And a future litigant may be tempted to defy a judicial ruling by disingenuously claiming doubt about its authenticity.” 

90. 91. 92. The judge imposed a sanction of $5,000 on each of two lawyers, and on the law firm. In Ex parte Lee 673 SW 3d 755 (Tex App Waco 19 July 2023) non-existent cases were cited to the Tenth Court of Appeals for the State of Texas. The court (Chief Justice Gray, Justice Johnson and Justice Smith) “resist[ed] the temptation to issue a show cause order… or report the attorney to the State Bar of Texas for a potential investigation for a violation of the State Bar rules.” In Kohls v Elison No 24-cv-3754 (D Minn 10 January 2025) the United States District Court for the District of Minnesota was concerned with a case concerning “deepfakes”. The parties relied on expert evidence about artificial intelligence. One of the experts had used generative artificial intelligence to draft his report. It included citations of non- existent academic articles. United States District Judge Laura Provinzino said:

“The irony. …a credentialed expert on the dangers of AI and misinformation, has fallen victim to the siren call of relying too heavily on AI – in a case that revolves around the dangers of AI, no less. … The Court thus adds its voice to a growing chorus around the country declaring the same message: verify AI-generated content in legal submissions!” 

93. 94. Judge Provinzino also referred to Park v Kim 91 F 4th 610 (2d Cir 2023) (where the court referred an attorney for potential discipline for including fake, artificial intelligence generated, legal citations in a filing) and Kruse v Karlen 692 SW 3d 43 (Mo Ct App 2024) (where an appeal was dismissed because the litigant had filed a brief with multiple fake, artificial intelligence generated, legal citations). Lacey v State Farm General Insurance Co CV 24-5205 FMO (MAAx), 6 May 2025, is a judgment of Judge Wilner sitting in the United States District Court for the Central District of California. The attorneys for the plaintiff submitted briefs that contained “bogus” artificial intelligence generated research, comprising fake citations and quotations. When two of these were pointed out by the court, the brief was re-submitted with those two corrected, but with many other fake citations and quotations still included. Judge Wilner referred to other cases where the same thing had happened, and the need for “a fact- and circumstance-specific analysis” before deciding what type of sanction to impose. He said:

“the conduct of the lawyers at K&L Gates is also deeply troubling. They failed to check the validity of the research sent to them. As a result, the fake information found its way into the Original Brief that I read. That’s bad. But, when I contacted them and let them know about my concerns regarding a portion of their research, the lawyers’ solution was to excise the phony material and submit the Revised Brief – still containing a half-dozen AI errors. Further, even though the lawyers were on notice of a significant problem with the legal research (as flagged by the brief’s recipient: the Special Master), there was no disclosure to me about the use of AI. Instead, the e-mail transmitting the new brief merely suggested an inadvertent production error, not improper reliance on technology. Translation: they had the information and the chance to fix this problem, but didn’t take it.”

95. Judge Wilner imposed litigation sanctions against the plaintiff and financial payments from the lawyers. In the course of his judgment, Judge Wilner referred to yet further instances of this issue: United States v Hayes (E.D. Cal. Jan 17, 2025) (sanctioning criminal defence lawyer for using artificial intelligence; when questioned by the court, the lawyer’s response about the source of inaccurate legal citations “was not accurate and was misleading”); Saxena v Martinez Hernandez (D. Nev. April 23, 2025) (“Saxena’s use of AI generated cases – and his subsequent refusal to accept responsibility for doing so – is just another example of Saxena’s abusive litigation tactics, and further explains why the court issued case-terminating sanctions”); United States v Cohen 724 F Supp 3d 251 (SDNY 2024) (declining to find bad faith where defence lawyer voluntarily disclosed that she “had been ‘unable to verify’” false citations in colleague’s brief and lawyer “would have withdrawn the [fake] citations immediately if given the opportunity”). 

Australia

[96] Valu v Minister for Immigration and Multicultural Affairs (No 2) [2025] FedCFamC2G 95 was a case before the Federal Circuit and Family Court of Australia seeking judicial review of a Tribunal decision. The written submissions filed by the applicant’s legal representative contained citations of cases and quotations that were not genuine. Judge Skaros referred the legal representative to the regulator. At [37], she said:

“There is a strong public interest in referring this conduct to the regulatory authority in NSW given the increased use of generative AI tools by legal practitioners. The use of generative AI in legal proceedings is a live and evolving issue. While the Supreme Court of NSW has issued guidelines around the use of generative AI, other Courts, including this Court, are yet to develop their guidelines. The Court agrees with the Minister that the misuse of generative AI is likely to be of increasing concern and that there is a public interest in the OLSC being made aware of such conduct as it arises.” 

New Zealand 

[97] Wikeley v Kea Investments Ltd [2024] NZCA 609 concerned the enforcement of a default judgment. The court (at [199] and footnote 187, per Muir J) noted that the appellant withdrew a written argument “after the apparent use of generative artificial intelligence in its drafting was drawn to our attention by respondent counsel”, that use being apparent “from the references to apparently non-existent cases.” It drew attention to guidance that had been issued by the judiciary as to the use of artificial intelligence in the courts and tribunals. 

Canada 

98. Zhang v Chen [2024] BCSC 285 was a case before the Supreme Court of British Columbia concerning parenting time with children. Ms Ke, the lawyer for the applicant, filed a document which cited non-existent cases. She explained her mistake in a note to a colleague: “I made a serious mistake when preparing a recent Notice of Application for my client, Mr Wei Chen, by referring to two cases suggested by Chat GTP (an artificial intelligent tool) without verifying the source of information. I had no idea that these two cases could be erroneous. After my colleague pointed out the fact that these could not be located, I did research of my own and could not detect the issues either. Regardless of the level of reliability of Al aids, I should have used more reliable platforms for doing legal research and should have verified the source of information that was going to be presented in court and/or exchanged with the opposing counsel. I have taken this opportunity to review the relevant professional codes of conduct and reflected on my action. I will not repeat the same mistake again. I had no intention to mislead the opposing counsel or the court and sincerely apologize for the mistake that I made.” 

99. Masuhara J said: “Citing fake cases in court filings and other materials handed up to the court is an abuse of process and is tantamount to making a false statement to the court. Unchecked, it can lead to a miscarriage of justice.” 

100. 101. He required Ms Ke to pay the costs of the additional effort and expense that had been incurred because of the reliance on fake cases. He also required her to review all her files that were before the court and to inform the court of any that contained citations or summaries that were obtained from generative artificial intelligence tools. Geismayr v The Owners, Strata Plan KAS 1970 [2025] BCCRT 217 was a case in the Civil Resolution Tribunal in British Columbia in which the applicants sought   retrospective approval for alterations made to a strata lot. Tribunal Member Peter Mennie said, at [25]:

“The Geismayrs’ submissions reference ten decisions where they say courts ruled that a strata could not force the removal of strata lot alterations. These cases have the parties’ names and the years published, but no legal citation. Nine of these cases do not exist. The remaining case… has three court decisions published in 2013, however, none of these are related to unauthorized alterations. The Geismayrs listed the source of these cases as a “Conversation with Copilot” which is an artificial intelligence chatbot. I find it likely that these cases are “hallucinations” where artificial intelligence generates false or misleading results.” 

102. In Ko v Li [2025] ONSC 2766, a case before the Ontario Superior Court of Justice, the applicant sought to set aside a divorce order. Ms Lee, counsel for the applicant, submitted a written document which cited non-existent cases. Myers J said, at [14] – [22]:

“14. This occurrence seems similar to cases in which people have had factums drafted by generative artificial intelligence applications (like ChatGPT). Some of these applications have been found to sometimes create fake legal citations that have been dubbed “hallucinations.” It appears that Ms. Lee’s factum may have been created by AI and that before filing the factum and relying on it in court, she might not have checked to make sure the cases were real or supported the propositions of law which she submitted to the court in writing and then again orally. 

15. All lawyers have duties to the court, to their clients, and to the administration of justice. 

16. It is the lawyer’s duty to faithfully represent the law to the court. 

17. It is the lawyer’s duty not to fabricate case precedents and not to mis-cite cases for propositions that they do not support. 

18. It is the lawyer’s duty to use technology, conduct legal research, and prepare court documents competently. 

19. It is the lawyer’s duty to supervise staff and review material prepared for her signature. 

20. It is the lawyer’s duty to ensure human review of materials prepared by non-human technology such as generative artificial intelligence. 

21. It should go without saying that it is the lawyer’s duty to read cases before submitting them to a court as precedential authorities. At its barest minimum, it is the lawyer’s duty not to submit case authorities that do not exist or that stand for the opposite of the lawyer’s submission. 

22. It is the litigation lawyer’s most fundamental duty not to mislead the court.”

NSW Health Inquiry

Findings in the detailed report from the Special Commission of Inquiry into Healthcare Funding are 

A fundamental assumption of this Report is that it is desirable for the State of NSW to have and fund a universal healthcare system. Universal healthcare coverage remains supported by the Addendum to the NHRA, as well as by provisions within the Health Services Act. Universal healthcare coverage is part of the social contract between Australians and their governments. 

The NSW health system is a good one. It comprises doctors, nurses, and other clinicians and workers who are well trained, highly skilled, and dedicated. It is well managed. The money allocated to NSW Health by a combination of NSW Treasury and the Commonwealth Government is not wasted. It is neither mistake nor incident free, but any person suffering an acute illness or injury that attends a NSW public hospital is likely to receive treatment and care comparable to the best that is provided in any other developed country. 

The system, however, has failings. One significant failure is that adequate and timely primary care is not available to parts of the NSW population. 

There has been a failure to embed prevention in all its forms into the health system, despite repeated and evidence based recommendations to do so. 

NSW public hospitals have many elderly patients in wards for extended periods of time beyond any need for acute care to be provided to them. These are people who could and should be cared for in aged care facilities. 

It is many years past the date from which the Commonwealth Government should have been working and collaborating on a regular basis with the NSW Government and NSW Health to ensure gaps in primary and aged care did not emerge, and to embed preventive services into the system and to fund them. 

There are parts of the health workforce who are suffering from “burnout”. At the time of writing, parts of the health workforce are engaged in industrial disputes with the State Government. Outdated awards, a decade long public sector “wage-cap”, and a lack of parity with pay available in other states have all contributed in varying degrees to that situation. 

Based on all I have seen in the last 18 months, the Long Term Health Reforms outlined in the Addendum to the NHRA, and its aspirations for “shared intentions” and to “work in partnership” towards a “nationally unified and locally controlled health system”, are currently (and have been for five years now) just words on paper. If that situation changes, it will be long overdue. 

The health of the population and the need for prevention: Chapter 10 

Chronic disease has become the leading cause of illness, disability and death in Australia, accounting for approximately 90 per cent of all deaths. Rising rates of chronic disease have a significant impact on the demand for health services. 

Targeted policies that address cohorts with higher rates of chronic disease – for example, those experiencing socio-economic disadvantage and those living in remote areas – can bring significant gains. 

The theory that compressing the period of morbidity that people experience may have healthcare cost and other economic benefits is the subject of considerable medical and economic literature. A vast amount of research and academic work has been undertaken suggesting that health services, programs, and policies aimed at disease prevention or early intervention have economic benefits. 

An ageing population (with high rates of chronic disease) will, as a matter of certainty, be one of the main contributors to the growth in demand for health services, and the growth in cost to the system. If NSW Health continues to be funded as a system that treats acutely unwell people in public hospitals, there is a risk its resources will soon be overwhelmed by what looms as a huge increase in healthcare demands by an ageing population with high expectations. 

The lack of funding or action to adequately prevent (or intervene early in) chronic disease is, at best, a curiosity. It should be a top priority. Not only for potential economic and cost saving benefits, but for population health reasons. 

“Prevention and wellbeing” is identified as a “priority” and “Long Term Reform” in the Addendum to the NHRA. This has not inspired much action. The evidence demonstrates a greater desire for ephemeral aspiration than the funding of anything actually aimed at “prevention and wellbeing,” ensuring it is done, and analysing the outcomes. No additional funding was provided for it in the Addendum to the NHRA. 

The Commonwealth Government does not fund the states, including NSW, to do much more than provide acute care services. Partly (but not solely) because of this, prevention is inadequately prioritised and funded in the NSW public health system. Despite being aware for decades of the need to assist health departments and agencies to shift out of a “reactive mode” and embed prevention firmly in the health system, governments - both State and Commonwealth - have largely prioritised shorter term markers. On the basis of an overwhelming amount of expert evidence, that must change. 

If one seeks to understand how much NSW Health spends on “prevention,” it is not easy to find a definitive answer. This might be explained by the imprecise way that “prevention” is defined. This is important: a lack of clarity concerning what is “prevention” can act as a barrier to transitioning the health system into a more preventive one, as well as leading to an undesirable opaqueness about claims made concerning expenditure on prevention. 

Executives within the Ministry of Health, management of LHDs, and the health workforces within districts are aware of the need to ensure adequate services are provided (including preventive health measures and community and home based care) to limit the number of people who must be treated in our public hospitals. Collectively, they have the expertise and skills to stand up a more proactive, prevention based health system. They cannot succeed in that endeavour without the required funding and leadership. 

“Prevention” of disease (or early intervention) is of such importance that preventive health should be expressly identified as a whole of government priority against which any new initiatives and policy proposals brought forward by all branches of government should be assessed. Prevention and early intervention must be firmly embedded into the NSW public health system. This will almost certainly require greater investment by the Commonwealth Government and the State of NSW in preventive services, as well as some different prioritisation. 

This priority should be informed and coordinated by a multiagency, multidisciplinary body led by NSW Health – ideally under the oversight of the Chief Health Officer. 

Primary and aged care: Chapter 11 

Primary care is a key component of all high performing health systems. The overwhelming body of evidence before this Special Commission reveals that the primary care system in NSW is under severe pressure, and a significant number of people across the State are not able to access comprehensive primary care. While I appreciate this is a funding responsibility of the Commonwealth Government, without meaningful action by NSW Health, this unsatisfactory situation will continue to deteriorate. 

With effective primary care, patient outcomes are improved, their need for specialist intervention or inpatient services is minimised, and unnecessary hospital admissions are avoided. Strong primary care is associated with improved population health outcomes for all cause mortality, all cause premature mortality, and cause specific premature mortality from major respiratory and cardiovascular diseases. Effective primary care is a more cost effective form of intervention than acute care delivered in the hospital setting, and increased availability of primary care is associated with higher patient satisfaction and reduced aggregate healthcare spending. 

The number of medical graduates pursuing general practice as a vocation has substantially decreased, while the numbers pursuing several specialities has risen. While the primary care system across NSW is generally under severe strain, it is particularly so in regional, rural, and remote areas. That strain manifests itself in various ways, from the complete absence of any primary care services in some locations, to practices with their books closed to new patients in others, a lack of accessible bulk billing practices, and long appointment waiting times. 

The reasons for decline in the availability of primary care are multifactorial. They include the inherent challenges associated with the operation of general practice, including increasing patient complexity, the perceived (and perhaps actual) inadequacy of current MBS rates, and the pressures associated with operating a small business (and their impact on the wellbeing of clinicians). Those challenges exist in all areas of the State, but can be more acute in regional, rural, and remote areas. 

Given the role of primary care in promoting and maintaining population health, it is of no surprise that there is a correlation between a decline in access to primary care and a subsequent increase in patients presenting to hospitals with higher levels of acuity. A high proportion of the population’s healthcare needs would benefit from consistent management in the primary care setting, particularly in circumstances where: a. 66 per cent of adults, and 26 per cent of children, are overweight or obese; b. 16.6 per cent of adults have diabetes; c. 36 per cent of adults have high cholesterol; d. 31 per cent of adults have high blood pressure; and e. 24 per cent of children are developmentally vulnerable in one or more domains in their first year of school. 

Most care for chronic conditions is provided in the primary healthcare setting by general and allied health practitioners. 

A lack of access to primary care also means that continuity of care – an important feature of effective primary healthcare, particularly for those with multiple chronic conditions – is difficult to maintain. 

Urgent Care Services or Clinics reduce pressure on Emergency Departments by siphoning off a proportion of the lower acuity patients who would otherwise be presenting. Viewed through the infinitely narrow lens of Emergency Department wait times, this might be seen as a solution to the problems caused by the absence of accessible primary care. Viewed more widely, it is plainly not. 

Urgent Care Services or Clinics are able to provide episodic care to a cohort of patients who require it. In some cases, that care could have been provided by a functioning primary care market. In others – such as care required afterhours – it may never have been met by conventional primary care and would instead have increased the patient load borne by the local Emergency Department. In this sense, Urgent Care Services or Clinics can make a positive contribution to the health services landscape. However, nobody should pretend that they are any substitute for effective primary care. They are not. 

The view that NSW Health should always prioritise acute care over the delivery of effective and accessible primary care fails to grapple in any meaningful way with the fact that the absence of adequate primary care will likely only increase the demand for “a service that only [NSW Health] provide[s]”; namely, that delivered through Emergency Departments or in the acute care setting, at vastly higher cost and with inferior long term clinical outcomes for patients. 

Whenever the State has stepped in to provide primary care through a salaried model or otherwise supported the delivery of primary care to a community where it is lacking, the State has obtained access to the MBS (a Commonwealth funding stream) to offset the cost of delivering that service. 

The view that it is not the function of the LHDs to invest in the provision of primary care is incompatible with their statutory purpose and functions as set out in ss 9 and 10 of the Health Services Act. Those functions include to “promote, protect and maintain the health of the residents of its area” and “establish and maintain an appropriate balance in the provision and use of resources for health protection, health promotion, health education and treatment services”. Activities directed to health protection, promotion, and education are not limited to acute care settings and, in many respects, are core functions of primary care. The statutory regime contemplates that LHDs will deliver the care needed to fulfil their stated primary purposes. In doing so, it does not draw a distinction between primary care and acute care, or hospital and community based services. 

Where a community is adequately serviced by a primary care market, there may be no need for the LHD to provide those services itself. However, where there is a thin primary care market, such that it does not meet the needs of the community, or no market at all, the LHD may need to provide primary care services (or support the delivery of primary care in a struggling market) consistent with its primary purpose and statutory function. 

There are several examples of where LHDs are currently doing exactly that in areas of need, including (among others) in the Murrumbidgee LHD, the Mid North Coast LHD, the Hunter New England LHD, Western NSW LHD, and the Central Coast LHD. LHDs – working in collaboration with PHNs and any existing service providers – are best placed to identify and address gaps in primary care services. That enables place based solutions to be designed having regard to the needs of the community, which may include the LHD itself providing, or providing support for, primary care. Those place based solutions necessarily include attracting a workforce to deliver the care needed in those regions. The overwhelming weight of the evidence supports a conclusion that clinicians who have historical links to regional areas, or who undertake their training in regional areas, are more likely to return to practise in them. Providing individuals with the opportunity to deliver primary care through a salaried position would likely enhance the prospect of professionals opting to commit to the delivery of primary care in rural and remote areas; perhaps with the added benefit of using that workforce synergistically to address workforce challenges in other areas of the public health system within the regions. 

As part of a place based response, consideration must be given to engaging a salaried primary care workforce, whereby general practitioners and other workers are employed by NSW Health to provide accessible primary care in underserviced areas. In the process of award reform, any barriers to this occurring – including what I have been told is a failure to specifically identify general practitioners as specialists capable of being employed as Staff Specialists in the current award – should be removed. To the extent that NSW Health provides traditional primary care services, the Ministry of Health should pursue funding from the Commonwealth Government – whether through s 19(2) exemptions or otherwise. 

Thin or failing aged care markets are also having a significant and detrimental impact on care delivered through public hospitals in NSW. 

On any given day, there are significant numbers of elderly patients occupying beds in public hospitals that could, if an aged care bed were available, be discharged. Patients in that category are described as “maintenance patients”. The high number of maintenance patients occupying hospital beds at any given time has financial implications for the NSW public health system, and creates risks for patients and staff. Maintenance patients are a high cost to the system. Those costs are borne by the LHDs. 

The large numbers of maintenance patients also create bed block, impacting the ability of a facility to move patients through the hospital. This in turn can result in ambulance ramping or the treatment of patients in the waiting room, which may not be optimal for all patients and may be unsafe in certain circumstances. 

When elderly patients are in maintenance beds, they are not in the optimal environment they should be. Being in a hospital beyond the time when a patient is clinically suitable for discharge brings with it certain risks, including hospital acquired complications, a higher risk of falls in elderly patients, and the effects of long periods of isolation away from their home environment and families. 

NSW Health suggested that by stepping in to address this problem, it would be “assuming responsibility for delivering services that are not only squarely within the Commonwealth realm of responsibility but also ancillary to health services”. This significantly oversimplifies the arrangements made under the Addendum to the NHRA. Victoria has maintained a presence in the aged care market and, like private providers of aged care services, is funded by the Commonwealth Government to do so. NSW Health has also maintained a presence in the aged care market through MPSs located in rural and regional areas. Commonwealth funding is provided for these services. 

Serious problems will continue to bedevil our public hospitals if something is not done urgently to address the lack of aged care beds available for the particularly challenging patients which the private market based providers will not accept. It is unrealistic to think that this problem can be solved without the State stepping in to play a greater role than it presently does in the aged care market – albeit it is entitled to be funded by the Commonwealth Government where it does so, at least to the same extent as would any other market based provider of aged care services. A similar issue arises in relation to patients who are suitable for discharge but waiting on National Disability Insurance Scheme (NDIS) acceptance and support. This has a similar impact on the bed flow of facilities to aged care patients. 

There are also instances where NDIS providers seek to relinquish care of their clients to district facilities, where the accommodation provider for that client does not have staff with the appropriate skill set to effectively manage the challenging behaviours of that client. Likewise, there are also “social admissions”, where the district becomes the “default provider” for NDIS participants due to breakdown of their living arrangements or carer fatigue and inability to obtain respite care. 

Although the evidence does not suggest that patients waiting on NDIS acceptance and unable to obtain appropriate support are creating problems of the same scale as those awaiting placement in an aged care facility, this situation should be closely monitored and action taken early to avoid the development of a system wide problem. 

First Nations Healthcare: Chapter 12 

In 2005, the then Aboriginal and Torres Strait Islander Social Justice Commissioner, Tom Calma AO, delivered his Social Justice Report, which recommended, (among other things) that: a. the governments of Australia commit to achieving equality of health status and life expectation between First Nations Peoples and non-Indigenous people within 25 years; b. the governments of Australia commit to achieving equality of access to primary healthcare and health infrastructure within 10 years for First Nations Peoples; c. resources available for First Nations Peoples’ health, through mainstream and First Nations specific services, be increased to levels that match need in communities and to the level required to achieve clearly identified benchmarks, targets and goals; and d. arrangements to pool the funding available for First Nations Peoples’ health should be made, with states and territories matching additional funding contributions from the Federal Government, with the ultimate objective of increasing the level of flexibility in the deployment of that funding pool. 

In the almost 20 years since that report was delivered (and despite the well intentioned efforts of many working within the public health system across Australia), little progress has been made in relation to what can readily be discerned as the objectives of Mr Calma’s recommendations.  

NSW Health is aware of the importance of Closing the Gap, and has taken action over a number of years in an attempt to improve services for, and health outcomes of, First Nations people. 

AMSs and ACCHOs are vital to the communities they serve. They are an indispensable, central hub of those communities. 

First Nations people are under represented in the medical, nursing and allied health professions in NSW. A strong First Nations health workforce is rightly seen as critical to ensuring cultural safety in the health system. However, there are unintended negative consequences of setting targets that NSW Health organisations must meet for their First Nations health workforce. AMSs and ACCHOs expressed frustration that they have long recruited and trained staff, only to lose them to jobs with higher salaries in LHDs or NGOs that have been given funding to provide First Nations health services but do not have the First Nations workforce required to deliver the service. 

No one within an ACCHO or AMS expressed any criticism of staff members who have moved to take up LHD roles, and they uniformly agreed that First Nations health workers should receive the highest remuneration on offer for the important work that they do. However, the cannibalisation of the workforce they recruit and nurture is a   substantial drain on their limited resources and makes it challenging for them to deliver the care required by their communities. 

Problems like this will persist in the absence of truly collaborative health service planning and delivery of First Nations health services. Only with constant and meaningful collaboration will it be possible for LHDs and ACCHOs/AMSs to properly explore opportunities to seamlessly coordinate services and share staff rather than having to compete for those that are in short supply. 

The importance of meaningful consultation and collaboration between NSW Health agencies and First Nations communities and care providers cannot be overstated. It is critical to ensuring that health services and research are culturally appropriate and has the added benefit of promoting efficient use of available resources. Effective collaboration can also help to prevent waste, avoid service gaps that exacerbate unmet need, and facilitate coordinated planning focussed on optimising outcomes. Meaningful consultation does not mean simply telling the community what is planned. It means identifying a specific community’s needs and priorities in collaboration with that community, and codesigning solutions. Needs may differ between communities, but systemic change is about policies and practice, and these must recognise the barriers experienced, including in rural and remote areas, through local consultation with First Nations people. 

Joint clinical service planning between ACCHOs, AMSs, and LHDs would address a lot of concerns. This would reduce duplication and allow them to work together to address workforce shortages and resource limitations. It would enable coordination of patient journeys in the community and in hospital, and collaboration to address issues earlier, rather than relying on siloed, output driven funding agreements. Joint clinical services planning would enable each group to optimise the value of their contribution and facilitate sharing of resources, communication and effective referral pathways in both directions. It is precisely what was recommended by Commissioner Calma. Aboriginal health services are underfunded. In addition, AMSs and ACCHOs have little autonomy as to how they can spend funds they receive, particularly from the Commonwealth Government. 

AMSs and ACCHOs could use funds more effectively from a health outcomes perspective if they were allowed to make the decisions about where to and to what extent they should allocate those funds based on the needs of their communities. Undoubtedly, they are best placed to make those decisions. 

The funding that those organisations receive is often short term. It should be blindingly obvious that short term funding in healthcare is undesirable. It makes the establishment and maintenance of health services and programs attached to that funding difficult to the extent that the funding almost becomes counterproductive. Workforce planning based on short term funding is stressful for everyone involved, and burdened by obvious disincentives relating to both recruitment and retention. 

Reporting requirements in relation to funding are considered burdensome. There is evidence that supports this view. That is not to suggest there should not be proper accountability for the use of public funds, including as to the outcomes achieved from funding particular projects or services. The preponderance of evidence, however, is that the administrative burdens on AMSs and ACCHOs relating to funds they receive from government is unreasonably onerous, time consuming, and a financial drain on them. 

Statewide Services: Chapter 13 

There are patients with a spinal cord injury who are not accessing the highly specialised care offered by the NSW Spinal Cord Injury Service, or who are not accessing those services in a timely way. This occurs because the NSW Spinal Cord Injury Service does not have a centralised registry of all patients with spinal cord injuries who may be receiving care without having been referred to the specialist service. A coordinated “State based” approach to the planning and delivery of highly specialised services like the NSW Spinal Cord Injury Service is critical to its effective operation. 

There are presently insufficient specialist rehabilitation beds at the Royal Rehab Group’s facility at Ryde and Prince of Wales Hospital to enable patient flow, and therefore those services are difficult to access. There are also associated bottlenecks in intensive care and the acute services at Royal North Shore Hospital and Prince of Wales Hospital because there are insufficient rehabilitation beds.  

The three adult brain injury units cannot presently provide traumatic brain injury rehabilitation for all people in NSW that require it because there are not enough beds. There has been no increase in the number of inpatient beds available in over 20 years. The inability of Statewide Services like these to keep up with population demand in part reflects the lack of central decision making in relation to the nature and volume of services to be provided. Similarly, there is no centralised decision making process for decisions relating to funding, the location of services, or staffing of services. For example, the various brain injury rehabilitation services are managed and funded by the LHDs in which they are situated, and the NSW Brain Injury Rehabilitation Program does not receive any funding directly for its services or patients. As a result, differences in the relative funding allocated to services within the NSW Brain Injury Rehabilitation Program can arise between LHDs. 

A centralised body – involving representatives of the Agency for Clinical Innovation (ACI), LHDs, and appropriate divisions or units within the Ministry of Health – should have oversight and responsibility for the governance and operation of supra-LHD and Statewide Services; including in relation to matters such as planning, implementation, funding, data management, performance agreements, monitoring outcomes and review of the ways in which services are delivered. 

Funding for Statewide Services should be allocated centrally, before flowing to the host LHDs via service agreements that clearly specify the services to be provided, as well as a series of measurable outcomes to be achieved. 

An effective centralised approach to the planning, funding, and delivery of supra-LHD and Statewide Services – facilitated and coordinated by the Ministry of Health – must necessarily draw on relevant expertise and knowledge from within the particular service, the LHDs which host those services, and other parts of the wider system, such as the Pillars.  

The delivery of paediatric services across NSW would be enhanced by the development of a Statewide plan and strategy dedicated to those services. There would be benefit in such a plan addressing matters such as: an identification of the services that can be expected to be provided in the specialist children’s hospitals and those services that sit within LHDs; how those services interact with and support each other; and a clear identification of the referral pathways into the specialist children’s hospitals (including referrals from general practitioners) and then back to local services for ongoing care and management. 

That plan and strategy could also support the development of approaches for LHDs to receive specialist support when managing paediatric patients through virtual care models, or a hybrid of virtual and face to face care. 

While its funding should be informed by the system wide service planning process discussed elsewhere, there is evidence that Justice Health is underfunded in relation to the demand for its services. It exists in a “capped financial environment” that does not appear to reflect (or be based on) the health service needs of the population it serves, and the extent of demand. 

Rates of obesity (and conditions associated with it) are high in prison populations. This becomes a burden on the public health system when prisoners with metabolic and related diseases are released. Funding should be provided (or redirected) to Justice Health (supported as appropriate by a suitably qualified group or agency within NSW Health) to enable it to set the diet of the prison population. 

There are bed block problems in transitioning patients under mental health orders from high security settings to medium and low security. This is the result of a lack of bed availability. This should change. No doubt the transition of patients from high, to medium, to low security settings is a complex matter for the most experienced relevant health experts. Those decisions should not be complicated by bed availability issues. That is not in the interests of the patients concerned, or the LHDs or communities to which they will return. 

There is also an issue in my mind as to the utility or appropriateness of the division of funding between Justice Health and Corrective Services NSW concerning psychiatric services (Justice Health) and psychological services (Corrective Services NSW). 

I am concerned enough about both of those issues to recommend that they be independently examined as a matter of urgency. 

Affiliated Health Organisations: Chapter 14 

The current processes for negotiating service agreements with AHOs lacks transparency in terms of their budget allocations. There is little in the way of genuine “negotiation” in relation to AHO yearly budget allocations. 

There is no reason why philanthropic funds donated to not for profit organisations should be used to subside the delivery of the public health system because the funding provided by NSW Health does not meet the cost of delivering certain services. The existing processes for AHOs to secure capital funding would benefit from improved transparency and certainty to promote longer term capital planning. There are significant budgetary and governance implications if they are unable to maintain the capital required to operate those services. Those risks flow to the public health system as a whole, which is heavily reliant on those organisations for the delivery of a range of services, including highly specialised services. 

AHOs should receive funding sufficient to cover the costs of delivering the services they are required to deliver under their service agreements. As a basal proposition, this much is accepted by NSW Health. 

It should not be assumed by anyone (including NSW Health) that, when assessing the fair cost of an AHO delivering any particular service, the unique circumstances of that organisation can be ignored. It is possible (maybe likely) that the fair cost of having an AHO deliver a service exceeds what it might hypothetically cost NSW Health if it were to attempt to deliver that service itself. To the extent that AHOs incur capital costs in connection with the delivery of the services required of them, these must also be taken into account in determining the level of funding that they receive. 

AHOs are, by reason of their status under the Health Services Act, part of the public health system. However, unlike LHDs, they remain independent organisations with their own legal obligations. Accordingly, if they do not receive funding sufficient to cover the cost of delivering services, their long term sustainability is at risk. While a series of negative results against budget for an LHD is not an optimal result, it does not risk their survival as an organisation, nor does it expose those responsible for controlling them to action for trading while insolvent. The same cannot be said of AHOs and their directors. 

AHOs are in an inferior bargaining position to the Ministry of Health or LHDs in their respective negotiations with them. There is a risk that this power imbalance will continue to operate to the detriment of AHOs (and the system of which they are a part) for so long as they are required to enter into service agreements with LHDs and thereby compete with all of the other services to be delivered by those districts out of their limited budgetary envelope. Adjusting the arrangements so that it is the Ministry of Health that is responsible for funding AHOs through service agreements may help to overcome these problems. 

Each AHO should enter into a single service agreement with the Health Secretary – in much the same way as currently occurs for the only networked AHO – and negotiations with those organisations regarding funding and the nature and location of services to be delivered under those agreements should principally occur at Ministry level. Relevant LHDs can, and should, be involved in that process when necessary. 

Planning the services to be provided by each AHO, and where those services are to be provided, should form an integral part of the wider service planning process discussed elsewhere in this Report. On an annual basis, and in conjunction with the planning and identification of the services to be provided by each AHO under their respective service agreements, Schedule 3 to the Health Services Act should be reviewed to ensure that it accurately records the recognised services and establishments of each of them and amended to the extent necessary to reflect those services. There is no good reason why it ought not be accurate at all times. 

A structured process should be implemented to promptly resolve any dispute between the Ministry of Health and an AHO regarding the extent to which funding offered is sufficient to meet the cost of delivering the level of service required under a proposed service agreement. Whatever process might be adopted, it must be independent, able to be unilaterally triggered by either the AHO or the Ministry of Health in the event of a dispute, and capable of meaningfully regulating the “purchaser/provider” nature of the relationship to be reflected in any subsequent service agreement. Such a process will not, however, interfere with or usurp the Minister’s power to determine the subsidy to be paid to each AHO. 

Single Digital Patient Record: Chapter 15 

NSW Health has commenced its SDPR project. Evidence suggests that the SDPR will bring many benefits to the health system of the kind discussed in the Strengthening Medicare Taskforce Report, and other reports. 

Something akin to an SDPR was recommended by Commissioner Garling more than 16 years ago. It is a failure of government that an SDPR has not been implemented in the timeframe recommended in that report (i.e., by 2013). 

A serious limitation of the SDPR is that there is no current plan for it to interface with primary care providers including general practitioners. There also does not appear to be a plan for it to extend to the St Vincent’s Health Network, or other AHOs. 

Access to the SDPR should be made available to primary healthcare providers. One advantage of linking the SDPR to primary healthcare providers, and in particular general practitioners, is that it will enable data to be collected about services provided by general practitioners, including preventive and chronic disease management services. It will enable greater connection and information sharing between those providing primary care services, and those providing acute services to the same patients. 

The SDPR should also be accessible to the St Vincent’s Health Network and other AHOs. Unless NSW Health rolls out the SDPR to them, it risks a fragmentation of access to important data within the NSW public health system itself; the very thing that it is intended to overcome. That is obviously undesirable, and could pose health risks and lead to inefficiencies. As to the St Vincent’s Health Network, it is a networked AHO, and operates a public hospital – the SDPR must be connected to it. This should not wait until after its expected completion in 2029. The cost of making the SDPR accessible to AHOs (in their capacity as part of the NSW public health system) should be borne by NSW Health. 

Planning: Chapter 16 

A robust health service planning function is critical to the delivery of healthcare in NSW. 

The capability of NSW Health to design and implement a feasible and successful system wide approach to health service planning relies on its decision making as to what the public health system is, and the boundaries of “the civil contract … between taxpayers and the Government about what [public health services] might be received in a particular community”; particularly in the context of a “constrained financial environment”. 

The current approach to public health service and workforce planning in NSW is not built upon a comprehensive understanding of population health needs from the bottom up. 

The widespread disinvestment in planning resources within NSW Health and dissolution of its service planning branches, as well as underinvestment in retaining planning skill at the LHD level, has fostered a “patchy” approach to service and workforce planning. 

The emphasis on workforce availability (rather than population need) as a driver of service planning reflects the deficiencies in the current workforce planning processes, as well as the limited integration of workforce and service planning. In particular, NSW has not “done a very good job of predicting ahead of time how many doctors [it will]   need, [and] how many nurses [it will] need”, nor facilitating collaboration between educational institutions and medical colleges for the delivery of that workforce. 

Because LHDs and SHNs have traditionally delivered facility based services, planning processes have had a tendency to be driven by the needs of capital processes, infrastructure and prioritisation of limited capital funds. This “bricks and mortar” approach is problematic. The “real planning need or the needs of [a] community [have] nothing to do with a facility”, and instead demand the provision of services in a community in a different way, for example, through extended general practice or extended scope of practice for nurses or allied health. 

The absence of strong systematic planning has fostered the development of services in response to other drivers, such as funding and workforce availability, political considerations, and historical service commitments. This method of growth has been ineffective in promoting patient safety and fiscal responsibility, and has culminated in a public health system that is increasingly being stretched unsustainably in an attempt to deliver as many services, in as many locations, as possible. 

There is a clear need to approach system wide health service planning in NSW in a way that better combines the local knowledge and assessment of LHDs and SHNs in relation to population health needs, in genuine collaboration with (and information sharing between) them and other providers of healthcare within their catchments, and overarching system wide coordination delivered through the Ministry of Health. Greater central involvement in planning is essential to identifying the most optimal and equitable distribution of services and (finite) resources across the State. The Ministry of Health should take on an oversight role for service planning, but this should not extend to dictating to LHDs and SHNs the way in which they are to go about delivering their services. This is a matter for local decision making. However, where the Ministry of Health is required to drive the development and maintenance of services that are necessary to service the population needs of more than one district, the Ministry of Health could drive that service delivery through purchasing and activity targets or specific initiatives. 

Publicly available planning documents should spell out the identified health needs of the community, the services that it is anticipated will be required to meet those health needs, and how (and by whom) it is intended that those services will be provided. These documents should also be explicit about what members of the community requiring those services should expect in terms of accessibility (including transportation arrangements, where necessary) and waiting times (the metrics around which will inevitably be informed by appropriate clinical evidence). The first step in the process must be the identification of the health needs of the local community. Unless community needs are identified, there will potentially be large gaps in service provision, including gaps that are invisible to service  planners. The health needs of a community should be the core consideration in place based planning. 

The identification of need, for the purpose of service planning, should involve population needs analysis, demand analysis, and analysis of socio-demographic factors, as well as genuine community engagement. In recognising that LHDs are but “a single organisation in a health ecosystem”, it should also involve engagement with other local organisations delivering services, in both the primary care and the acute care sector, to determine both the quantitative and qualitative needs of the community. 

The “needs identification” step of the process will inevitably be best informed by a ground up approach, whereby LHDs and SHNs with intimate knowledge of the needs of the populations they serve and the associated health matrix can feed information into the planning process while also using information flowing down from the Ministry of Health, which has a broader understanding of service availability within the State. 

The next step in developing an approach to service planning is deciding what services should in fact be delivered by the public health system in order to meet the identified need. This involves a broader consideration of what the public health system is and what it can deliver in an economic and safe way. There is a need for NSW Health to consider, first, what services fall within the ambit of the “public health system”, and secondly, how the public health system can operate to offer those in scope services to the people of NSW in an optimal and equitable way. That will require decisions about what services should be provided and where. That must be done in a coordinated way across the system as a whole to ensure the optimal deployment of resources. This must be done as part of an open collaboration with community and other providers of healthcare to that community. 

Community engagement around health services planning must be a genuinely consultative process. Telling the community what has been decided after a planning decision has been made is not consultation. Good community consultation requires a high degree of transparency. 

Albury Wodonga Health: Chapter 17 

As a general matter, it is not optimal practice for any health infrastructure to only be conceived and designed around a particular sum of money that happens to be available. That, instead, is an optimal way of risking the wastage of precious public funds. 

The money said to be available for health infrastructure should not drive service delivery. Rather, any infrastructure spend should be based on what the health service needs of the catchment population are and will be, which themselves will be based on a variety of factors such as (but not limited to) population growth, ageing profile, and various socio-economic factors. 

There is little evidence to suggest that the proposed redevelopment of the Albury Hospital was based on this kind of analysis. Equally, there is little to suggest that the proposed redevelopment of Albury Hospital has had meaningful regard to the views of the medical and other clinical workforce of Albury Wodonga Health, of management, or of the community. While those views are not determinative of any particular outcome, there must be meaningful engagement with them, that appears to be either absent here, or at best insufficient. 

Workforce: Chapter 18 

The NSW public health system’s most important asset is its workforce. 

The health workforce in NSW is comprised of dedicated and highly skilled people, who everyday work to provide high quality care to the people of NSW. There is, though, now a need to take steps to ensure that the public health system will have the benefit of such a workforce long into the future.  

The causes of the current workforce challenges facing NSW Health are multifaceted. Some reflect societal changes – such as shifts in how and where people want to work – which will take time to address. Others are what might be described as system issues relating to how NSW Health plans, engages, and deploys its workforce. 

Most of the awards and other instruments setting the terms and conditions of employment or engagement for NSW Health workers do not reflect contemporary work practices. They have not been reviewed substantively for many years. Many terms of those awards date back decades. There was general consensus (except in relation to the Public Health System Nurses’ and Midwives’ (State) Award) that NSW Health awards are outdated and no longer fit for purpose. Many awards are overly long, not drafted in plain language, are frequently ambiguous, and replete with inconsistencies and incoherences (both internally and with other awards dealing with similar professions). The number of awards dealing with allied health professionals lacks any rational explanation except for history. There is an urgent need for a broad project of award reform in respect of NSW Health awards. Recent history suggests that, if that does not occur, NSW Health, and the industrial organisations and their members, will likely continue to be engaged in a rolling series of negotiations and disputes. Indeed at the time of writing this Report, and throughout the duration of this Special Commission, negotiations and disputes have been ongoing. 

Extant Visiting Medical Officer Determinations have not been updated since 2014 and require modernisation. 

There presently exists a disparity in the rate of pay between NSW and other Australian jurisdictions for some of the health workforce. That disparity was cited as being a factor in some of the difficulties experienced in recruiting and retaining a permanent workforce, particularly in some specialties and regions. 

Whether pay parity is ultimately to be achieved or not, there can be no genuine controversy that the pay and conditions of health professionals in NSW should be appropriate to the work performed. Health professionals in NSW should be fairly and reasonably compensated for the value of their work to the system. This will require an assessment of the nature of their work, the skill and responsibility involved, and the contribution it makes to the system, including any changes in those qualities since the last “work value” assessment. The contribution a profession makes to the system should be viewed broadly, not as limited to questions of productivity, efficiency, or savings. 

There are overall shortages in applicants for some specialist training programs, such as psychiatry and emergency medicine. Modelling indicates “significant” career opportunities in psychiatry, diagnostic radiology, ophthalmology, and rehabilitation medicine, as well as neurosurgery. Those “significant career opportunities” correspond with a relatively high number of additional trainees needed each year to meet projected demand. 

A shortfall in applications for internship positions or for vocational training positions – at least in relation to some specialties – will impact the future workforce. It is from those pathways that the future medical workforce (including specialists) develops, an extensive or prolonged shortage in those pipelines has the very real potential to lead to future shortages in that workforce. 

There have also been shortages of specialists to fill available positions in psychiatry, emergency medicine, radiology, and anaesthesia, as well as general practice. Many, but not all, of those shortages are seen in rural and regional NSW. The underlying causes of workforce shortages in rural and regional NSW are multifactorial, but include: a. a perception (which may be mistaken) that work in rural and regional areas is less interesting and professionally satisfying while being more onerous (including in relation to on call obligations); b. a perception of a lack of professional and social support in rural and regional areas, especially for those clinicians who trained in metropolitan areas; c. insufficient financial incentives for metropolitan based clinicians to relocate to rural or regional areas; and d. limited employment opportunities for spouses and partners of clinicians, a lack of suitable accommodation, childcare and other services in rural and regional areas. There are significant shortages of midwives and enrolled nurses across the State, and (as with the medical workforce) a maldistribution of the nursing and midwifery workforce between metropolitan and rural and regional areas. 

The shortages in the nursing and midwifery workforce in some rural and regional LHDs correlate with difficulties in attracting students for clinical placements and applicants for graduate positions, notwithstanding the range of incentives, scholarship, and cadetship programs aimed at increasing the attractiveness of rural and regional work. Those shortages are also reflected with a greater use of agency nurses in those areas. 

There is value in data that analyses “aged vacancies” - i.e., vacancies in respect of permanent positions that have been advertised but unfilled for some time. Data of that kind is likely to assist in identifying and quantifying the extent (and duration) of a shortage within the permanent workforce at a facility or across a region. The Ministry of Health should take steps to capture and consider data of that kind as part of an enhanced, system level, service planning process into the future. Modelling indicates that some allied health disciplines are experiencing significant shortages compared with service demand, including, for example, radiation therapy, sonography, psychology, podiatry, and occupational therapy. Maldistribution of the allied health workforce is also a significant issue in most disciplines. The reasons for those shortfalls and workforce maldistribution in the allied health workforce are complex but include: a. competition from the private sector and NDIS providers, which typically pay more and offer more flexibility; b. at least a perception of reduced career development or progression opportunities, particularly in rural and regional areas; and c. insufficient supervisors to supervise complete clinical placements for those under training. 

Currently, there is no system wide approach to workforce planning, in the sense that the clinical workforce is not established or structured by reference to a detailed assessment of population needs or the supply of clinicians across the system. The need for a system wide approach to workforce planning and engagement has increased in recent times as the effects of “pressure” on the health budget, and workforce shortages and maldistribution have become more acute. Difficult choices must be made as to what services are made available, where, and in what form if the system is to be sustainable into the future. The advantage of a system wide perspective in responding to that new environment is that it provides an opportunity to maximise the efficient delivery of health services across the State by ensuring the most effective deployment of its workforce and budget to achieve that aim. It is essential that the Ministry of Health has a key role in that process, given that it alone has oversight over large amounts of workforce data and the ability to analyse and interpret that data at a system level. It also effectively controls the funding allocated to local organisations to fund their workforce needs. 

The current structures have given rise to the untenable situation of parts of the system competing with one another for agency nurses and locums. That results in parts of the NSW public health system bidding against each other, which only results in increased cost to it. 

The need for a system wide approach to workforce planning does not mean that the benefits of devolution are to be discarded. To the contrary, local perspective and input remain critical to effective planning. 

One significant benefit of a centralised workforce planning function that leverages the oversight and expertise within the Ministry of Health is that it will provide NSW Health with the ability to better observe the impact of the actions or policies of external stakeholders and societal changes on NSW Health workforce (including its future workforce pipeline), and to plan and implement a response to them. 

There is no central coordinating function in relation to clinical placements, which can lead to competition between universities for those placements. 

There is considerable scope to enhance the planning, establishment, and allocation of clinical placements for university students and vocational training positions for registrars, which will likely deliver significant benefits to the system. 

As part of a system wide approach to workforce planning, there should be greater strategic coordination and planning related to clinical placements and vocational training. HETI is well placed to take a leading role in that process, and to perform that function going forward. 

While HETI administers a central computer based system (ClinConnect) that facilitates the “booking” of students into placements, there is no central coordination of where placements are established or how students are allocated to them. This approach creates some obvious problems, including that: a. either universities or local organisations end up competing with each other depending on whether demand for placements exceeds supply in the relevant local area or the reverse; b. the matching of students with placements is largely manual rather than allocated in the nature of, for example, the medical intern program; c. because the matching of supply and demand occurs locally and is largely based on relationships, there may be a supply of students at one university and a demand for students at a local organisation that are never matched with one another because there is no central coordination or visibility; d. there is a duplication of administrative work because of the need for both universities and local organisations to make and administer multiple arrangements with one another, with variable terms; and e. there is no central monitoring or direction as to the number of clinical placements that should be established or where they should be established in order to match demand for placements, or future service requirements. 

As a result, NSW Health is not able to obtain the benefit that may flow from a more coordinated approach to the allocation of university placements and recruitment of those being placed into identified areas of need at the time of their likely graduation. A more strategic, whole of system approach to allocating clinical placements that aligns (so far as possible) with projected future demand for clinicians in the relevant field is necessary. 

The coordination of clinical placements is a function that is best located within HETI, working in close collaboration with Ministry of Health and the LHDs and SHNs. HETI must be appropriately and adequately resourced to perform that role. In doing so, there should be quarantined funding for those roles (perhaps in the form of clinical educators) within HETI that are the interface between universities, students and local organisations to ensure that local organisations are appropriately supported to deliver high quality and effective student placements over the medium to long term. Such roles must be protected from broad brush “efficiency” programs. 

Effective consultation between health system management and clinicians is an integral part of a highly performing health system. The Medical Staff Council (and other councils provided for in the Model By-Laws) provides a mechanism for that to occur and for management to harness the benefits of the collective experience and expertise of its clinicians in matters affecting the delivery of care at their hospitals. If Medical Staff Councils (and the other councils) are to achieve that aim, they must provide an effective means of consultation and engagement at the facility and district or network level. 

In order to strengthen those processes, the Council structures set out in the Model By-Laws should be reviewed. The role and purpose of each Council should be clearly identified, and they should be complementary of each other. 

Following that review, the Model By-Laws should be amended to clearly articulate the purpose and role of each of the Councils, and how they relate or interact with each other. 

Having the Chairs of each Council observe Board meetings can only enhance the discourse between management and clinicians. Where a Board has determined not to extend an invitation to Council Chairs to attend Board meetings, they should implement a procedure whereby the Board shall receive reports from the Chair of each of the Councils within their district or corporation on a regular basis (at least quarterly) as to matters that fall within the remit of their respective Councils. 

The complaints and grievance policies would benefit from wholesale review and simplification. NSW Health accepted the benefits in doing so, and some work in this respect is under way. 

There are high levels of fatigue, stress and “burnout” across the NSW Health workforce. 

While the COVID-19 pandemic undoubtedly contributed to this, that high rates of burnout persist within the system should be seen by all of those with an interest in maintaining a strong and effective health workforce as troubling. It is something that must be addressed in a meaningful way, and as a matter of priority. 

Given the extent of burnout and low levels of staff wellbeing across the system, more detailed data on those matters should be routinely collected across the system. That will then provide the basis for targeted initiatives (which may differ in different locations) to support and enhance the wellbeing of the workforce and reduce staff distress, including that which is occasioned by burnout. 

Funding: Chapter 19 

The question of whether the system as a whole is “underfunded” is complex and cannot be answered solely by reference to demand indicators. It requires consideration of what the NSW public health system should be, including the nature of the services that should be available, where those services should be offered, and the timeframes in which patients can expect to be treated. It is only once that system is identified and designed that the necessary funding levels, and optimal models, can be identified. 

The historical origins of the “base” figure for funding in the NSW health system – including the size and shape of the health system that it was at least conceptually supposed to have supported – are unknown by those within the Ministry responsible for the preparation of budget submissions, and those within Treasury currently charged with considering and making recommendations in relation to them. That is not a criticism. However, in circumstances where no one can identify the origin of the base from which the NSW Health budget has been (and is being) set, the base cannot be said to reflect an assessment of the level of funding required to deliver a public health system that meets the current and emerging health needs of the population, or that is required to “promote, protect and maintain” the health of the population. Matters such as cost growth and forecasted activity growth are considered in the budgetary process. However, those are matters that inform a consideration of what it would cost to operate the public health system to continue for another year in its existing form. They say little (if anything) meaningful about the cost of delivering a public health system that is best placed to meet the health needs of the population. In order to determine the level of funding required to deliver a public health system that meets the needs of the population, it is first necessary to gain a detailed understanding of: what those needs are, the services that are available (both within NSW Health and from other providers) to meet those needs, and what (if any) additional services are needed. That analysis is best performed as part of the system wide planning process that must now be undertaken. 

A budget process that does not enable executives or Board members of an LHD (some of whom had extensive business and accounting experience) to readily understand how the budget has been prepared is a process that demands immediate improvement. LHD Board members are offered modest renumeration for the responsibilities they have. An LHD Board cannot discharge its functions unless given a budget that is capable of being readily understood. They should not have to reengineer it to be able to understand it. 

Within some parts of the system, the funding available is (at least currently) insufficient. For example:  a. the funding available to many of the LHDs and AHOs does not enable them to deliver the services necessary to meet the needs of their populations, and maintain infrastructure; b. LHDs have experienced significant budgetary challenges when opening and operating new facilities in circumstances where the ongoing funding made available to them does not meet the cost of doing so and; c. Justice Health does not presently attract the level of funding it requires to meet the demand for its services, with “patients waiting longer than clinically recommended, across all services waitlists”. 

Further, there is under-resourcing or underfunding (including by the Commonwealth Government) in aspects of: a. primary care (including general practice services and allied health); b. mental health services; c. community health services; d. aged care; e. dental services; f. paediatric services; g. preventive health services; and h. health services for First Nations people. 

Ultimately, the funding model should not be “the tail that wags the dog”. Rather, the funding models that are adopted by the Government to fund the NSW public health system, and by the Ministry of Health to fund the public health organisations (and the system more widely), should be those that best support the delivery of the public health system that the Government (through NSW Health) aspires to provide. A central problem with the provision of health services in NSW is the funding divide between it and the Commonwealth. 

There is a series of “Long Term Reforms” in the Addendum to the NHRA. The Commonwealth Government – the polity with the most financial power in Australia’s federated system – has not shown any great inclination to act on these reforms, or to (sufficiently) fund them. 

The Addendum to the NHRA will not achieve its aims unless the State and the Commonwealth Governments can sit down and agree on a funding envelope so that the states, including NSW, are adequately funded to provide health services when and where they are needed that are aimed at reducing rates of chronic disease (including early intervention) as well as having people “age well”. 

Having identified, through a system wide planning process of that kind, the health system that the NSW government (through NSW Health) aspires to deliver to the people of NSW, the Ministry of Health should – with expert guidance – reformulate its approach to funding so as to devise a funding structure that will ensure that the LHDs and SHNs are sufficiently resourced to deliver that system. That will inevitably include blended, bundled, or other funding mechanisms. 

Services provided by NSW Ambulance have changed over time. Many health services now provided by NSW Ambulance are aimed at (and achieve the goal of) keeping people out of the hospital system and Emergency Departments if there is an appropriate alternative. Between 25 to 30 per cent of “incidents” addressed by NSW Ambulance now do not result in transport to a hospital. 

While NSW Ambulance now routinely adopts this as its approach, its budget still has its origins in its prior role of being “ambulatory first aid.” To that historical budget, growth including from “ad hoc political announcements” has been applied. What has not been done, however, is a comprehensive analysis of the services the modern NSW Ambulance and its staff provide, with funding based on that reality. That should now occur. 

Procurement: Chapter 20 

Delivering the highest value healthcare for the money expended should be a priority in any procurement process – a concept that is sometimes described as “value based healthcare”. As NSW Health rightly submitted, the concept of “value for money” is broader than “value based healthcare”. Accordingly, it must be remembered in any consideration of NSW Health’s approach to procurement that, in the wider government context, a range of criteria beyond monetary value must be incorporated into procurement plans and tender evaluation processes. 

The concept of “value” in healthcare should involve a consideration of value not just to an individual patient and those with a direct stake in their care, but to other stakeholders in the system including clinicians and the broader community. 

The principal object of centralised procurement should be to ensure that NSW Health achieves the best value for money spent. Only through careful modelling will it be possible for HealthShare to determine which arrangement will deliver greatest value to the entire system. If that arrangement results in rural and remote LHDs paying more for a particular item, or incurring significant freight costs in having goods delivered from a centralised warehouse, it may be that equity can only be achieved through adjustments to the funding provided to those LHDs, rather than seeking to equalise pricing through procurement in a manner that risks system wide value. 

Complexity is inevitable in a system of the size and scope of NSW Health, particularly when that occurs within a government context that introduces a range of legislative and NSW Government requirements. NSW Health has ongoing procurement reforms. There are undoubted benefits in NSW Health continuing to: a. consolidate its procurement policies, processes and systems where practicable; b. provide clear, practical guidance to staff at all levels of the system (and not just procurement staff) to the steps they need to take to procure different kinds of goods and services; and c. ensure that assistance is readily available if staff experience difficulties. 

Innovation: Chapter 21 

While a more robust approach to what might be considered to be significant and “game changing” innovations is both necessary and appropriate, there is also a need to adopt a similarly thorough approach to the identification, assessment, prioritisation, and implementation of innovations that target the current burden of disease and public health issues and trends that are prevalent within the community. 

There is a risk that ground breaking innovations that, by their nature, will benefit a smaller patient cohort may receive disproportionate attention and support compared to those with the potential to enhance health outcomes for more of the population, thereby yielding greater overall economic benefits and improving the health of many more people. That is not to say that innovations that are likely to benefit smaller patient cohorts are not important and should not be pursued. 

There are limitations in current funding models and approaches that impact on efforts to drive and implement innovations across the system. For example, it has been suggested that activity based funding (ABF) can limit the capacity for local innovation that may produce wider system benefits if pursued. There may also be concerns that adopting a new model will have a negative financial impact in an ABF context because it will result in reduced activity and, therefore, will generate lesser reimbursement. 

Those limitations in current funding models sit in a context where, unlike some other jurisdictions, NSW does not have an “innovation fund” (or something similar) that is capable of being drawn upon to support innovation across the system. Innovation and research are, in general terms, insufficiently supported. An example of such a fund is the $2 billion fund that was established in 2020 by the Victorian Government to stimulate industry investment in life sciences. 

Unless enough resources are committed to embed implementation of innovation into the system, it is unlikely the benefits will be sustained. That is because change in clinician behaviour and for the relevant processes to be integrated and become business as usual takes time. As a consequence, the ACI takes a cautious approach to the number of initiatives it rolls out Statewide at any one time. That can result in some promising programs not being scaled for wider application due to the time that it will take to implement them, particularly in circumstances where a LHD does not see a particular innovation as a priority for their population.