The Brereton Report: what the military can learn from the health system

Nov 26, 2020

The Brereton Report makes for uncomfortable reading. Its findings and recommendations principally focus on individuals and their conduct, including unlawful acts, wilful misreporting, falsifying records, failing to exercise proper control over subordinates, giving false evidence and suborning colleagues to give false evidence. There are a handful of recommendations in relation to culture but they tend to focus on operational matters and training.

Several important lessons from the health system can and should be applied to the Australian military. This might seem a strange and implausible connection – health and the military – but not so long ago hospitals and their nursing staff were established and run along military lines. It has long been observed that nursing was ‘born in the church and bred in the army’ and, until nursing education moved into universities in the 1980s, the most inexperienced recruits were on the ‘front line’, making rigid obedience to orders and meticulous attention to minor detail critical for both staff and patient safety.

What has changed for health?

First, the evidence has shown that strict hierarchical structures are not conducive to patient safety. Programs such as ‘speaking up for safety’ encourage and educate even the most junior nursing and medical staff to raise their concerns when they believe the system might be unsafe. Bullying has been recognised as endemic within these hierarchical structures and active anti-bullying campaigns and programs are in place, although there is always more to be done. In addition, the administrative hierarchies have been flattened. The chief executive’s office is open to all. Chief executives regularly walk the floors and hold town hall meetings.

Second, when high-profile medical mishaps occur, internal and external reviews and formal inquiries, such as the 2008 Garling Report into acute care services in NSW public hospitals, demand the identification of cultural and organisational changes to prevent a recurrence. This focus is at least as important to the health system as is delivering redress to those who have been adversely affected and taking action against those found at fault. When things do go wrong, the system encourages open disclosure and a just culture and important protections are given to whistle blowers.

Third, governance arrangements have changed to allow other voices to be heard by the senior leadership team. The days of hospital boards being comprised solely of doctors are long gone. Hospital boards must meet community expectations on diversity and inclusion and have members with backgrounds that include other health professions, patients and carers, business, risk, governance, stakeholder engagement, NGOs, IT, marketing and communications. We know from the Banking Royal Commission that ‘group think’, a slavish adherence to orthodoxy and cognitive bias are the enemies of innovation and change. Diversity delivers strength and ensures that hard, uncomfortable and novel questions are regularly put to management.

Fourth, even though health focuses diligently on things that have gone wrong, learning from excellence and understanding resilience in healthcare are helping health services and their staff to focus on what goes right, and to capitalise on the goodwill and expertise at every level in the services .

Fifth, partnering with consumers at every stage of health service delivery is growing into a critical element of the co-production of health care. Studying, understanding and acknowledging the impact of the work we do on the people we do it with and for is critical to the improvement of services, even when sometimes the feedback from those partnerships may require us to do radical re-thinks.

Finally, hospital administrators are expected to accept accountability for high-profile medical mishaps and systemic problems, especially if they could have been known or uncovered by asking the right questions.

These developments have made for a much better, more agile and more resilient health system than we had a century ago, even if it might not be immediately recognisable to Florence Nightingale. Naturally, there are still chains of command. Excellence and compassion continue to be delivered. There are flexible and evidence-based models of care that guide and standardise decision making.

The arguments that the military is somehow different because of its mission and its traditions and that civilians do not understand the issues and challenges applicable to the military are redolent of similar arguments that were once put forward about the health system. Those arguments are outdated and no longer hold water. The military has shown its ability to adapt to modern civilian laws on work, health and safety and the environment. There should be no reason why the positives from the health system could not be applied to the Australian military.

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