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06 Dec 2018

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA

There is no doubt all doctors want to offer high quality care to all their patients. Of course we make occasional mistakes and no one should under-estimate how much we berate ourselves for those. And occasionally they weigh very heavily. We all struggle to a variable degree in managing these internal musings; dealing with ambiguity and facing up to errors and unintended deficiencies wrought by our hand that cause regretful harm.This aspect of professionalism and learning from these internal musings is a critical part of our training and continuing development, and is a defining dimension of being a doctor.

What then is the best way to promote high quality care? Regulation is becoming onerous in the (political) pursuit of quality care. I think the parenthesis is important here. An interesting article by Elkin in the Medical Journal of Australia in 2011, examining doctor discipline between 2000 and 2009 under the (new) Australian Health Practitioner Regulation Agency (AHPRA) regime showed the discipline rate to be reducing. The discipline rate was 6 per 10,000 doctors. In 78 per cent of cases the tribunal made no mention of physical or mental harm to patients as a result of the misconduct. By contrast, penalties were severe with 43 per cent of cases resulting in removal from practice and 37 per cent in restriction of practice. 

Ponder then the very significant increase in complaint rates in the last decade in all jurisdictions. In my home State of Queensland, under the yoke of the relatively new Office of the Health Ombudsman, in their 2016-2017 report they note a nine per cent increase in complaints (compared to the previous year)  to 10,262. But only 13 cases in the same time period were referred to the tribunal and only 10 serious investigations requested from AHPRA. The point here is – regulation loving Governments are pouring money into more expensive medical regulation systems to promote patient safety (and by extension ensure quality), with no real sense or data that there is a problem of declining quality or increasing patient harm at the outset. It could be construed that this is a very expensive political outcome for no real gain in promoting quality or safer health care.

So what about another Government invention to promote safety and quality – the HAC! Hospital Acquired Complications are now punishable by reduced funding – the Independent Hospital Pricing Authority (IHPA) pricing system is truly mind boggling and quite impressive. 

I was asked recently to review the respiratory failure section of the weighty and solemn tome detailing hospital acquired complications. I started hopeful and optimistic that this document would live up to the effort and hype.  Disappointment was swift. There did not appear to be a clear definition of what constituted respiratory failure (in this context) and there was a fatiguing, unenlightening but painfully earnest discourse on the basics of respiratory care that would not have surprised any doctor, nurse, physiotherapist etc. In fact, the commentary definitely strayed towards condescending and it occurred to me to wonder what audience the authors had in mind given I imagined anyone who worked in a hospital would likely find the chapter I read unhelpful and a tad insulting. The talk about penalising avoidable re-admission is similar – something we know has no evidence basis when tried overseas e.g. in regard to chronic obstructive pulmonary disease (COPD) re-admissions. Negative. Misguided. Probably unhelpful.

This all made me ponder a case I heard about recently where a penalty was applied for a HAC – in this case a pressure area. This cachectic but mobile patient with metastatic cancer had fractured their foot and needed a Moon boot. He was in hospital receiving palliative care and a chest tune-up. There was family and community supports being brought to bear and so on. The boot unfortunately led to a hidden pressure area under the boot on the leg which was dealt with when discovered. The hospital was penalised for allowing a pressure area to develop. Regrettable – without a doubt. Unintentional – certainly.  Avoidable – hmmmm, I guess, but easier said than done. Such a vulnerable patient receiving various treatment, (including chemoradiotherapy) – has this penalty hit the mark?  Was there a particular system failure?  Are patients safer in future and has the application of the HAC penalty driven a pursuit of higher-quality care?  I do not think so on all counts. What did the penalty achieve then?

The problem with these penalties devised with political intent in mind and a ‘thin’ evidence-basis is that you foment discontent and erode confidence in regulation and system management. Moreover, and perhaps more worrying, it drives gaming behaviour among institutions to avoid penalties and preserve operating viability. One potentially begins to practice a more risk-averse style of medicine that is often more expensive, subjects the patient to more tests/interventions and consumes greater resources. All this when there was not really a problem with patient safety and the quality of health care to begin with!  There are too many sticks!

We should ask the architects and promoters of greater medical regulation and/or the Hospital Avoidable Complication list what carrots there are for beleaguered doctors to offer good quality care? System architects need to be very careful that they are not leading us into an adversarial system where avoidance of risk and penalty become paramount with no compensation or recognition of extra effort or superlative service and care.  Let’s please also have some carrots!


Published: 06 Dec 2018