8 September 2017

Subversion of compliance – a new form of abuse

Government Medicolegal

Late last Friday afternoon I received an unsolicited email, instructing me to respond within 48 hours. There was no indication of whether the time limit was literal, and failure to comply would significantly disadvantage a third party.

The email was from a government entity, and instructed me not to reply to the source of the email – no-one would be responding to enquiries.  Directed to a website (no automatic link) I completed a turgid, poorly designed referee’s report for a young doctor seeking to negotiate the complex annual re-employment nightmare that our health system imposes.

The application was submitted weeks ago, but the deliberately anonymous bureaucracy was happy to mandate this two-day window for my response. I assume that if a willing referee is sick, on leave or taking a weekend off for some work life balance then the poor applicant suffers the consequences.

Readers will recognise this dilemma. The digital/electronic era has insidiously normalised a culture that no longer asks if we would like to do something, and we no longer have any negotiating rights when responding. We can disregard the framework of “good manners” that traditionally defined appropriate behaviours in complex societies. Instead we accept that requests and regulations can be imposed with no input from us, no option to challenge and no-one to complain to if it seems unreasonable.

Does this matter? At one level it is simply another manifestation of faceless bureaucracy, recognisable in many historical eras and cultures.

However, we should note that times of bureaucratic dictatorship are invariably associated with a denial of individual rights and the subjection of significant subsets of the population to discrimination and persecution.

When does a request become a threat or form of abuse?

The recent Centrelink and Australian Tax Office debacles were ostensibly valid requests for information, but on scrutiny demonstrated a serious abuse of individuals and their rights.  Many of my patients, individuals with no power or authority, were threatened by heavy handed and highly resourced monolithic entities. They had virtually no chance of contact with an individual with a real responsibility to the client, nor any meaningful ability to deal with their valid concerns about threats and spurious demands.

The healthcare sector is not immune to this “compliance abuse”. The MyAgedCare and NDIS bureaucracies have paradoxically managed to undermine the construct of patient-centred and needs-based care. The irony would be amusing if the consequences weren’t so serious. Ask any client or clinician who has attempted to negotiate those systems and you will uncover a torrent of “compliance abuse” experiences.

There is, of course, a need for regulations and compliance. These constructs underpin civilised society, and are designed to prevent crime, fraud and abuse – to protect individuals, particularly the most vulnerable.  However, recent years have seen a huge increase in compliance requirements and an inexorable shift away from protection and towards control. Any protections afforded have tilted away from the vulnerable individual and in favour of controlling entities.

I recently had a patient in my surgery in tears. A man trying to balance his family life with his workplace of 20 years, he reported that in the past year new compliance regulations had come into his industry at a rate of one every two workdays – a staggering 120 new regulations in the past year, with no existing compliance requirements eased. This is a stupendous indictment of our society, and yet we seem to accept it without question.

An egregious recent example of “compliance abuse” was suffered by my 92-year-old patient who has developed a rapid onset total blindness, transitioning from independence to requiring round-the-clock care in her own home. After months of effort to regain her confidence and mobility, I found her this evening emotionally crushed and back in her wheelchair.

A faceless manager at the care organisation had deemed that she could only walk using a frame, and forbidden the care staff to assist her personally, even though they had done so willingly in the past and were at no risk, given her tiny build. Neither patient nor carer was permitted to exercise judgment or autonomous thought.

This is not risk management – this is callous indifference and abuse.

Compliance abuse is now a deliberate and effective form of bullying and discrimination.

Invariably, abusive compliance requirements benefit the interests and perspectives of one party, with no option for negotiation or refusal. We accept them as a necessary means of getting through our day-to-day business.

It is not difficult to differentiate the abusive from the ethical. The next time you are reminded of your compliance obligations simply ask yourself: is this designed to assist or support me or my patients, and was my input sought in designing the instrument?

If the answer is “no”, then it may be time to politely challenge the basis of the regulation!

Professor Simon Willcock is Clinical Director of Primary Care at Macquarie University Health Sciences Centre in Sydney