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Dr John Stokes discusses the link between financial reward and systemic bullying in the health sector, the ramifications for patients and urgent need for reform.

I AM A SENIOR DOCTOR nearing retirement with a career involving teaching, service development and clinical work.

A year ago, I opened my e-mail one night and was immediately dumbstruck. A complaint containing several untrue serious allegations about myself had been lodged with the regulation authority and furthermore I was given only 14 days to answer the allegations.

The “in good faith” vexatious complaint alleged I should lose my registration. Several months later, after investigation proved the allegations to be false, another letter notifying me of another vexatious complaint with more serious untrue allegations was received. These allegations were also found to be without foundation.

At the same time, in my work as hospital director of medical services, I was bullied and harassed by several senior doctors at every official meeting I attended. I later became aware that a letter with similar untrue allegations had been sent to the Australian minister for health with copies to the prime minister and to the leader of the opposition. I was not sent a copy of the letter.

Vexatious complaints are a reality of modern medicine in Australia and they are evidence of the intimidating lengths some practitioners will go to destroy a reputation and a career — and to protect a monopoly.

Last year, a group of senior health practitioners formed a new national health association called Health Professionals of Australia Reform Association (HPARA). HPARA was formed to correct the manipulation, misuse of authority and unfair application by the Australian Health Practitioners Regulation Agency (APHRA).

The regulation and registration of health practitioners has been injurious to many individuals and has had a deleterious effect on the delivery of health services. The aim of HPARA is to improve APRHA so that its important role in upholding standards for safe care is not impaired but, at the same time, assumes innocence until proven otherwise, protects professionals from unintended harm during investigation and, most importantly, prevents and holds accountable vexatious complainants misusing the process.

The founding group is a diverse range of health professionals from many regions of Australia and includes retired specialists, practicing specialists and a nursing practitioner. All of these professionals have experienced or witnessed damaging and flawed handling of complaints by our national regulatory body, which resulted in poor outcomes for patients and about which the health professionals complained.

In most cases, natural justice, fair procedure and the assumption of innocence were not observed. Some involved obvious vexatious complaints, yet the complaints were treated as valid by the regulation authority. Complaints can be repeated against individuals until the the accused person's employment and participation in health delivery ends.

The regulatory system in Australia is unable or unwilling to address the damage done to our health service by its inability to recognise this problem. The essential problem with AHPRA and its function is that, in a significant number of actions, it neglects to be impartial or fair, or to observe natural justice. It accepts the status quo. The primary aim of our organisation (HPARA) is to correct the injustice that results from such an approach.

Underlying this, is the reality that current health practitioners and health delivery managers, in both the private and the public sector, are driven to derive and increase income for item numbers for procedures and bed-days — rather than to address public health needs. Those professionals providing such item numbers and bed days reap enormous reward and power.

Financial reward drives our system in ways we – and even the founders of Medicare and health insurance – had not envisaged. The result has been that health expenditure in Australia is increasing in real terms faster than inflation, the population and population ageing. Figures from the Australian Institute of Health and Welfare show that health expenditure has increased from 6.5 per cent of GDP in 1989-90 to 9.7 per cent of GDP in 2013-14.

Furthermore, it appears health expenditure is increasing at a rising rate. We have the health equivalent of the mining boom, with some health providers seeking profit instead of improved care.

All human activity, including the delivery of health, is affected by self-interest, whether it is for money, power or sex. Recently, behaviour exposed in the health workplace has demonstrated the truth of this observation. Examples of bullying by some practitioners have now been alleged to be motivated by demands for sex, maintenance of monopoly and sustaining powerful positions and financial gain in the workplace. The problem is thought by many to be much wider than recently reported examples. 

The health delivery market is, in general, a closed shop for a privileged anointed few. AHPRA, which regulates health service providers, takes its advice from professional organisations and is often closely aligned with their views. These professional organisations – which are able to control entry into the workplace, access to postgraduate education, the opportunity for specialist training and the required ongoing recognition to participate in the workplace – have enormous control of the system by being able to advise APHRA.

Many of these advisors are made up of health practitioners with vested self interest who occupy non-transparent senior positions in, and are accountable only to, their professional organisation. They are not accountable to the health consumer or to the Australian population they should serve. Their communication networks are not transparent, they are protected by anonymity and are difficult to uncover. Few of those “in the know” about this are willing to speak out for fear of personal consequences in the work place. Our senate has recognised this problem and will hold an open enquiry into the administration of health practitioner registration by the Australian Health Practitioner Regulation Agency in the next few months.

As I approach my retirement I am in awe of the technological, pharmacological and public health advances we have made in health over the last 50 years. I could give many examples such as better immunisation, improved eye surgery, better cardiovascular disease management, improved joint replacement, better cancer services and less invasive body imaging procedures to name a few. In contrast to most industries, though, it is doubtful that health worker productivity has increased. Cost, however, has escalated enormously, incomes have risen and competition is near non-existent in the delivery of these advances.

The reasons for this lie in the fact that our health providers, their colleges, professional organisations, unions and our health administrators are not working together and, most importantly, are not prioritising the needs of patients. Instead of providing leadership to drive efficiency, all of them are continually asking for more money and resources. Spending more and increasing financial incentives has not been shown to improve productivity in the health sector.

These organisations often use issues of patient safety, shrill shroud waving and the claims for maintenance of standards to protect their status quo and also, as alluded to above, to remove some effective practitioners. We, in HPARA, recognise there is a “clique” to which you must belong, comply with and never challenge to be successful in a career in health care. Break ranks and this closed shop will use its control of regulation and registration to bring you undone. There is a clear need for reform and removal of this threat. 

But HPARA's wider value and important implications lie in leading the way to a better system of health delivery. How can this group do this? They will do this by a much needed Australia-wide push for reform of APHRA to open up new opportunities to stop these vested interests, break the monopoly of power and remove the ineffective and often failed pernicious incentives of our health system.

If we are to reform health delivery for Australians – which is vital for our ageing population and to manage the challenge of a rapidly growing health budget – Australians have to recognise these system faults and introduce measures to correct them as rapidly as is possible.

If we don’t accept this and do not act, the Australian health budget will continue to grow exponentially, sap the vitality of our workforce and consume our finite resources. The start of this work needs to be at the level of reforming APRHA and its archaic approaches to registration and regulation. AHPRA must not be the tool of the colleges and other health organisations but must work in the interest of the Australian population.  

There is now a widespread view that there is already enough money allocated to the delivery of health services, albeit much of it wasted in duplicated and disparate federal and state systems. It is time to use these resources more efficiently. By default, those organisations mentioned above have the power to do this but have no incentive to do it.

In a similar way to the slow progress in the reduction of the health gaps for our Indigenous population, we have mainstream health systems in place that can easily block reform of our health system regulation. Despite spending more we are slipping behind in offering fair and efficient delivery of health care to our population. We must start with our regulatory system if we are to achieve reform.

To use similar words to our Prime Minister we ask,

Is this the time in Australia to see these challenges as exciting enough for us to accept and is our country innovative enough to confront and solve these problems?” 

Being optimists we believe if we shine the light of day on the processes that are now in place, foster transparency and make those of us in health care accountable, we can accept the challenge and have a chance to make a difference for our entire population.

The reform of APHRA is a challenge that HPARA intends to put forward and to address at its first Australia wide meeting to be held in Sydney on 8 April 2016. The call for a Royal Commission is worthy of consideration.

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