Patients deserve it. Staff deserve it. And the future of healthcare certainly depends on it.
When a clinician makes an error, the process that follows is clear and transparent.
The Australian Health Practitioner Regulation Agency investigates, standards are applied, and consequences follow. This framework exists for one fundamental reason – to maintain public trust in the safety and integrity of healthcare.
Yet when executives or healthcare boards make decisions that compromise patient safety, suppress staff concerns, or obscure organisational risk, there doesn’t seem to be such equivalent oversight.
Why do we regulate clinicians but not the people who lead them?
While leadership decisions can shape the culture, priorities, and safety of entire health systems, surprisingly leadership itself remains quite unregulated. We’ve built a comprehensive structure to govern the actions of individual practitioners, but none to govern those whose decisions actually determine the conditions in which those practitioners work.
The hidden accountability gap
Across Australia’s hospitals and health services, critical decisions about staffing, escalation, and patient flow are routinely being made behind closed doors. These decisions shape not only operational efficiency but also the safety and wellbeing of patients and staff.
Yet the governance processes surrounding them often lack the much-needed transparency and independent scrutiny that should be warranted.
This gap also extends to those situations when clinicians or health leaders raise legitimate safety concerns in relation to some of these decisions. All too commonly, these individuals are branded as “difficult” or “disruptive.” Some are then surreptitiously excluded from leadership pathways, and others are removed from rosters or quietly exited from employment contracts altogether.
Under these circumstances, for those working in the private healthcare space particularly, such as visiting medical officers who operate as contractors rather than employees, the absence of unfair dismissal protections under the Fair Work Act can leave them especially vulnerable.
Whistleblower protections, where they exist, are often either inconsistently applied and/or are rarely enforced. The result is the creation of a system where speaking up and “speaking truth to power” can come at a significant personal and professional cost.
Sadly, existing governance mechanisms that are intended to protect openness and accountability itself can, in practice, often be weaponised or used as tools for self-preservation.
Risk systems are repurposed to manage reputations rather than safety. Reports are diluted, escalations are delayed or ignored, and many uncomfortable truths are heavily sanitised before they reach decision makers. Over time, this pattern normalises dysfunction and embeds silence as the only survival strategy within organisations.
The consequences are then, of course, quite predictable, as preventable harm often persists not because of inadequate clinical competence, but because of leadership failure and the absence of independent oversight.
When leadership failure kills
History has repeatedly shown that systemic harm rarely begins at the bedside. It very often starts in the boardroom.
In the Mid Staffordshire NHS Trust (UK), financial targets and reputation were prioritised over patient care by the health leadership. The result was a public inquiry and the uncovering of hundreds of patient deaths that could have been avoided.
The Bacchus Marsh (Djerriwarrh Health Service in Australia) scandal revealed preventable perinatal deaths that were attributed to data suppression and governance collapse.
And the Phoenix VA Hospital scandal in the US, with alleged falsification of waiting-list data that led to the death of veterans, triggered a congressional inquiry and investigations by the Office of Inspector General and the FBI, with findings of “systemic leadership failure”.
Different countries, same pattern. Gatekeeping, denial, retaliation, and the absence of independent scrutiny.
Why leadership isn’t regulated. Yet
Australia’s clinical regulation is recognised as among the world’s most robust. But what about governance regulation? Regrettably, not even on the radar.
Boards answer primarily to their own internal codes and to ministers or health departments, often with agendas of their own. But there’s no independent body with the power to investigate or sanction healthcare executives and board directors whose decisions lead to systemic patient harm.
In the finance sector, the Australian Securities and Investments Commission can suspend or ban directors who breach their duties.
Related
Why then do we not have the same expectation and standards for the health sector? Is safeguarding the health of financial portfolios more important than protecting the health of humans themselves?
The case for an ‘AHPRA for leadership’
If ASIC safeguards the integrity of corporations, and AHPRA protects patients from clinical negligence, then healthcare needs that crucial third pillar: a “Health Governance and Leadership Oversight Agency” (or however named).
Its purpose and approach wouldn’t be punitive, but one that is centred on prevention and trust.
Here’s what that could look like:
Independent oversight with real powers: A standing commission or agency with statutory authority to investigate and sanction healthcare executives and boards. Not just after inquiries, but proactively and before harm occurs.
Protected reporting channels: Anonymous, legislated reporting avenues for clinicians, nurses, paramedics, and VMOs, ensuring those who speak up are protected, not punished.
Transparent public reporting: Publishing of annual governance audits and public reporting of clinical and operational outcomes to drive visibility and improvement.
Executive and director KPIs that measure integrity in decision-making: Redesigned performance systems that incorporate patient safety, staff wellbeing, and appropriate escalation responsiveness as core metrics of success and executive career progression.
Embody cross-sector scope: Because governance failures aren’t just confined to hospitals. They ripple across ambulance, aged care, and community health.
This concept is far from being just theoretical.
International experience offers us some clear precedents. The UK’s Care Quality Commission, Health Services Safety Investigations Body, and Professional Standards Authority collectively illustrate the impact of independent oversight, transparent reporting, and system-wide learning.
These organisations have shown that visibility and impartial inquiry can elevate governance standards, strengthen public confidence, and drive continuous improvement across health systems.
While these are not without their limitations, they herald the principle that even those who enforce standards must themselves be subject to oversight.
By understanding and addressing known limitations from the start, such as meaningful enforcement powers and comprehensive, legislated protections for whistleblowers, we are uniquely positioned to build on these foundations in Australia as well.
To ensure accountability extends beyond just inquiry and apology, into effective action, prevention and meaningful oversight is the hallmark of gold standard governance.
From crisis to the way forward
Ambulance ramping, access block, financial unsustainability, clusters of the same root causes that keep resulting in the same patient harm, are our persisting new normal.
These are not discrete problems, they’re all a constellation of signals and symptoms of a system where leadership accountability is optional. Until we hold healthcare leaders to the same professional standards as clinicians, Australia will remain stuck in its familiar cycle of Inquiry – outrage – apology – repeat.
An “AHPRA” for health leadership could change this pattern.
It could embed courageous accountability at the top of the system where it matters, and not just at the frontline.
Our healthcare system mostly runs on trust. Trust between patients and clinicians, clinicians and leaders, leaders and boards. When that trust erodes, regulation can at least stand as the last line of defence.
An “AHPRA” for leadership isn’t about targeting executives. It’s about protecting the integrity of good leadership, giving it structure, legitimacy, and the public confidence it deserves.
Because patients deserve it. Staff deserve it. And the future of healthcare certainly depends on it.
Dr Alwin Tan is the faculty advisor for the Australian Institute of Health Executives.
Dr Sidney Chandrasiri is the CEO of the Australian Institute of Health Executives.
This article was first published by the AIHE. Read the original here.