Is resistance protecting patients from unsafe reform, or is it protecting the loss of power from what may be necessary change?
Across more than 80 years of Australian health policy, a remarkably consistent pattern seems to have emerged.
A major health policy reform is proposed. Doctors and lobby groups raise concerns about patient safety, clinical autonomy, professional standards, government interference or the integrity of the doctor-patient relationship.
The debate escalates. Sometimes it goes to court. More often, it’s fought out politically. The reform is initially delayed, diluted or reframed. And then, in many cases, the reform is implemented anyway.
The Pharmaceutical Benefits Scheme, Medibank, Medicare, nurse practitioner scope, pharmacist vaccination, pharmacist prescribing.
And now, potential specialist fee regulation.
These were not identical reforms, but taken together, they tell an important story for healthcare leaders.
When the medical profession resists reform, are they protecting patients? Or are they protecting the existing distribution of power?
Now that is where governance begins.
The long memory of reform resistance
This pattern goes back more than 80 years.
In the 1940s, the Pharmaceutical Benefits Scheme was challenged because sections of the medical profession viewed it as a step toward nationalised medicine. The concern was about what government involvement in healthcare might eventually mean for medical independence.
Initially, the scheme was delayed, but the policy returned, and today, it’s impossible to imagine Australian healthcare without the PBS.
The same pattern is seen with Medibank and Medicare.
Universal healthcare was not supported by national consensus. It was contested fiercely. Sections of the medical profession argued that it would weaken clinical independence, interfere with the doctor-patient relationship and depress professional incomes.
Those arguments carried significant political force, because Medibank was initially dismantled after its introduction, before then evolving into the more enduring version of universal health insurance, Medicare. Today, Medicare is considered a national pillar.
Health leaders should pause here.
Because it’s interesting how many policies that now seem so obviously necessary, were once regarded by professional groups as unacceptable intrusions. The issue is not simply that doctors were wrong. It would be too easy, and too unfair, to reduce this history to a claim that “doctors always oppose progress”.
Doctors are often the first to see the clinical risks in poorly designed reform. They understand complexity at the point of care in ways that policymakers, managers and consultants sometimes may not.
This is why professional resistance can in fact be a useful warning signal, because it can reveal gaps in accountability, training, indemnity, continuity and safety.
But any resistance does also need to be interpreted with a greater degree of scrutiny, because the language of patient safety can sometimes carry two different messages at the same time.
One message is legitimate: “Will this reform protect patients?” The other, is more political: “Will this reform reduce our control?”
The difficulty for healthcare leaders is that both these messages can sound identical at the beginning.
Across the decades, organised medical opposition has tended to intensify when reforms threaten to do one or more of these four things:
- redistribute funding;
- expand who can provide care;
- alter who holds clinical authority; and/or,
- increase government influence over price and access.
In much simpler words, resistance seems to become strongest when reform threatens power.
The modern version of an old debate
The more recent debates around the clinical practice scopes of nurse practitioners and pharmacists are best understood through this lens.
When nurse practitioner roles expanded, the concerns raised were familiar: patient safety, accountability, scope, standards and fragmentation of care. These are not trivial concerns, because expanding scope without clear governance can certainly create risk. Poorly integrated models can fragment care. Title confusion can mislead patients, and clinical accountability matters.
But the deeper questions were also about authority and jurisdiction:
- Who is allowed to diagnose?
- Who is allowed to prescribe?
- Who is allowed to manage defined episodes of care?
- Who gets access to Medicare funding?
- Who is recognised as a legitimate clinical decision-maker?
These are very much professional boundary questions.
The same applies to pharmacist-administered vaccinations.
When this was proposed, the objections included concerns that pharmacies were not appropriate clinical environments and that vaccination required medical assessment. Yet over time, pharmacist vaccination has now become quite routine.
It didn’t dismantle general practice. It didn’t end the essence of medical care. It just expanded access through another channel.
This doesn’t mean that every expansion of pharmacist or non-medical scope should be accepted unquestioningly, but it does mean that healthcare leaders should be cautious about inadvertently mistaking professional discomfort for system harm.
There is indeed a very clear difference between a reform that is unsafe versus a reform that is unfamiliar. But there is also a very clear difference between protecting patients and protecting a monopoly over access.
Why doctors resist reform
The reasons are a lot more complex than self-interest alone.
First, medicine has a deeply internalised duty to protect standards. This is one of the profession’s strengths. Doctors are trained to think about risk, complications, missed diagnoses and unintended consequences. In healthcare policy debates, that instinct can be invaluable.
Second, clinical autonomy is a concept that is closely tied to professional identity for doctors. Many doctors view autonomy as necessary to advocate for patients, resist poor management decisions and practise according to clinical judgement, which is why when government or other professions appear to encroach on that autonomy, the response is often visceral.
Third, the profession has a long memory of poorly implemented reform. Doctors have seen policies introduced with ambitious language and inadequate resourcing, weak governance or little understanding of frontline realities. That history creates scepticism.
Fourth, medicine operates within established financial structures.
Fee-for-service income, specialist billing, referral flows, procedural revenue and professional status can all be directly affected by health policy change. It would, of course, be naïve to pretend that the risk to personal finances plays no role in resistance, but it would be equally naïve to suggest that it is the only factor.
Fifth, professional power is often defended through the language of public interest by every profession.
This is not unique to doctors. Lawyers, engineers, accountants, nurses, pharmacists, managers and executives, all defend their domains using arguments that blend genuine public concern with institutional self-protection.
Medicine is simply more visible because its authority is so central within the health system.
The hidden asymmetry in reform debates
Healthcare leaders should recognise the structural imbalance in why and how these debates sometimes unfold.
The asymmetry is that the risks of any reform are often visible and immediate, while the risks of not reforming can often be dispersed, delayed and less politically impactful.
Things like a missed diagnosis, a prescribing error, or patient who was harmed because a new model was not governed properly, is real, visible and demands immediate attention.
The patient who could not access a GP, the older person waiting months for care, the emergency department absorbing failure from the rest of the system, the family who couldn’t afford a specialist gap or the public hospital carrying the downstream cost of private market failure – these are much harder to comprehend as tangible, clear-cut harms that fit neatly into a box.
That asymmetry matters because professional opposition tends to focus on the visible risks of potential change, while the invisible risks of the status quo remain in the periphery.
Good healthcare leadership of course, requires holding both.
The question shouldn’t just be, “is there any risk in this reform” because there will always be risk. The better question is, “compared with what”.
Related
Specialist fee caps: a new frontier in an old contest
The emerging debate about specialist fee caps sits very squarely within this 80-year pattern.
It’s not just about pricing. It’s really a debate about the boundary between private professional autonomy and public affordability.
If and when out-of-pocket costs become a barrier to care, private pricing stops being a purely private matter, because it becomes a system access issue. That is when governments understandably eventually intervene.
The response to this from the medical sector is also understandable, yet predictable. Fee regulation will be framed as interference with clinical independence, a threat to workforce viability in the private sector, and potentially an unconstitutional overreach.
Some of these arguments indeed do have merit.
Poorly designed pricing caps could create perverse incentives, reduce access in some areas, or push costs elsewhere. Therefore, any serious policy in this space would need to consider workforce supply, procedural complexity, geographical maldistribution, and the perceived difference between reasonable remuneration and excessive fees.
But the broader direction that seems to be coming is hardly surprising, because whenever public funding, private billing and patient affordability collide, government will eventually be compelled to step in and test the limits.
Healthcare leaders shouldn’t be shocked and outraged by that. They should be anticipating and preparing for it.
Learning from history
The real value of this history is not in judging the past, it’s in improving how healthcare leaders can interpret the present.
When any health policy reform is opposed by a professional group, health leaders should start asking some sharper questions:
- Is the objection primarily clinical, economic, professional or political?
- What evidence is being leveraged, and what evidence is being ignored?
- Are the risks of reform being compared honestly with the risks of inaction?
- Who benefits from maintaining the current model? Who is excluded by it?
- What safeguards would make the reform safer, rather than simply slower?
- Is a profession being asked to give up control, income, identity, or all three?
These questions may be uncomfortable because they move the debate beyond blindly repeated slogans, but they will also prevent health leaders from falling into one of the two common traps – dismissing doctors as obstructive or accepting professional resistance at face value.
Both demonstrate poor leadership by alienating the very people needed to implement the reform well and ignoring what could be legitimate clinical warnings.
The action then is not to silence professional resistance, but to interrogate it.
Reform requires governance, not just courage
Governments are notorious for often underestimating the implementation of health reform. They announce the reform, win the political argument, and assume the system will adapt.
But that’s unrealistic and adaptation is not automatic.
If scopes expand, oversight must be mature. If new professions prescribe, accountability must be clear. If pricing is regulated, consequences to access must be monitored. If care shifts settings, information flow must follow. If autonomy is constrained, clinicians need confidence that bureaucracy is not replacing judgement.
Reform without governance can create the very risks its opponents warn about.
Healthcare leaders should see these debates as governance issues rather than policy contests or having to choose sides.
The deeper lesson
The deeper lesson from 80 years of reform resistance is that healthcare reform rarely launches itself as progress, and initially looks a lot like disruption.
Which is why reform is often resisted.
It’s not because doctors don’t care about patients or default to seeing every reform as unwise. It’s because asking a powerful profession to accept reform in which it remains essential, but no longer autonomous, is a very difficult transition.
The next time a major reform is opposed, healthcare leaders should resist the temptation to ask only whether there will be opposition, because there certainly will be.
They should instead ask what the reform stands to redistribute. Is it access? Income? Authority? Accountability? Or professional identity?
Because it’s here that the initial seeds of resistance often take root.
And then they should ask the harder question of what the resistance to the reform is protecting:
- Is it protecting patients from unsafe reform?
- Or is it protecting the loss of power from what may be necessary change?
The answer of course will not always be simple, but it is one of the most important distinctions healthcare leaders can make.
Dr Sidney Chandrasiri is the CEO of the Australian Institute of Health Executives.
This article was first published by the AIHE. Read the original article here.
