• David Gardner

Support vs Fear in regulation

Sometimes regulation of health care is painted as an “us vs them” scenario. Practitioners against patients, hospitals against patients, hospitals against practitioners, with regulators against everyone.

The “us vs them” adversarial approach overlooks the fact that a better regulatory system actually rewards everyone – practitioners are happier (because they’re not being crushed by the system, but supported by it), hospitals and other health facilities operate better and more safely, and – most importantly – patients get better care.

Unfortunately, the adversarial approach is the current approach of AHPRA and the National Boards. This can be shown by the fact that, as of 1 July 2019, of the last 15 news articles on AHPRA’s website:

  • 9 celebrated penalties in Tribunals or Courts;

  • 2 related to accreditation agreements;

  • 1 threatened practitioners with potential action if they did not adequately support public health programs (While supporting these programs is important, the message was clearly a threat – containing statements such as “If practitioners do not comply and meet the professional standards set by their National Board, regulators can and do take action.” - a far more effective message would have been to highlight the ways in which practitioners can, and do, support those programs, and to celebrate the work done by the vast majority of practitioners in doing so;

  • 1 provided advice to practitioners about dealing with notifications (I should note here that although I think the content could be greatly improved, the regulator should be recognised for what appears to be an attempt to provide better information and support to practitioners – it would be a significant and positive change if more focus was placed on this aspect of the regulator’s work); and

  • 1 was a positive statement recognising osteopaths for their work

Two thirds of the news articles are about punishing practitioners or other individuals.

It is vital that the regulator holds unsafe practitioners, or unregistered people, to account. Left unchecked, those people can cause significant harm to the public.

However, those people form a tiny percentage of the practitioners regulated by AHPRA and the Boards. 99% of practitioners are safe, competent, and want to do their jobs well. Even among those who make mistakes, the majority recognise their errors or shortcomings and actively seek to improve.

AHPRA and the Boards ought to take a far more positive approach that seeks to support practitioners, assist them in practising more safely.

Instead, the current approach is one of instilling fear into practitioners – fear of doing the wrong thing, and of being investigated and disciplined. This leads, inevitably, to practitioners practising defensively.

Years of research into best practice in managing people has indicated that threatening disciplinary action, and introducing a culture of fear in the workplace, leads to:

  • Poor morale and workplace culture;

  • Poor performance by staff; and

  • A workplace in which covering things up, and not being honest, is rewarded.

An example of this is a hospital that wanted to reduce needlestick injuries. Its approach was to inform staff that the first time they notified the hospital that they had suffered a needlestick injury, they would receive a formal warning. The second time would likely result in termination(!).

There is no doubt that staff, when placed in the situation, will simply not report the issue to the hospital. The hospital lost an opportunity to understand why needlestick injuries were being caused, and to try and assist staff to reduce their incidence – instead, it promoted a culture where those injuries would be covered up, despite the likely adverse outcomes that would lead to.

Similarly, rather than seeking to scare and punish, the regulator ought to consider the impact that its approach has on practitioners and the way in which they practise. Practitioners ought to feel safe and protected in the knowledge that if they practise their profession to the best of their ability, AHPRA will leave them alone.

However, that is not the case. Practitioners are currently terrified of AHPRA. This is not a failing of practitioners, but a failing of the system.

It seems unlikely that AHPRA or the Boards will adjust their approach – if anything, recent developments within the organisation have only exacerbated this issue.

Given that, it is likely that an overhaul of the entire system is needed - the real question, however, is what it would be replaced with. Unfortunately, examples of good health regulators are sadly lacking.

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