The Levers You Already Hold

Written by Jayde Fuller

By Jayde Fuller

Prefer to listen? Jayde reads this piece (19 min).

Health regulators say the system is too complex to change. But behaviour is forced in only a few places, and most of the effort goes to the one place that binds nobody.

Too complex to change?

Every regulator says the system is too complex to change. Every regulator controls a licence.

Those two facts don't sit together.

The complexity is real, and I won't pretend otherwise. Take health regulation in any of the countries I work across. It has multiple professions, each with its own board or college. It includes education providers, accreditation bodies, employers, funders, tribunals, and ministers, plus overlapping statutes that each read differently. When someone says Indigenous-specific racism in healthcare can't be fixed by any one organisation, they're describing that system accurately.

But look at what they're describing. It's a map of who talks to whom: who reports to which minister, whose standards feed whose, and which committee signs off on what. It's an organisation chart.

It isn't a map of where behaviour is forced.

That's a different map, and it's much simpler. However complicated a regulatory system looks from above, there are only a few places in it where someone's conduct is required rather than encouraged, where not doing the thing has a consequence. Those points don't multiply as the system gets bigger. They're where authority actually sits.

Most regulators have drawn the first map many times. Very few have drawn the second.

Five levers, ranked

Here are the levers a health regulatory system holds over racist conduct, ranked from the hardest binding to the softest.

1. Registration and codes: binding on every practitioner

These bind every practitioner, because they're conditions of practising. In Australia, the shared Code of conduct adopted by twelve National Boards since June 2022 directs practitioners to "acknowledge and address individual racism," and defines culturally safe practice as healthcare "free of racism." The medical and nursing professions carry equivalent content in their own codes and standards.

The Medical Board has made cultural safety education a requirement for specialist registration from October 2024. Continuing professional development for doctors now has to include culturally safe practice and addressing health inequities. None of these is a suggestion. Registration depends on each of them.

2. Accreditation: binding on institutions

Accreditation binds education providers, and through them every future health practitioner. The Australian Medical Council's current standards for medical schools, in force since 2024, raised the bar on First Nations health and cultural safety. First Nations academics at the University of Wollongong put it plainly this year: the shift has come "not through a collective critical consciousness within medical education institutions… but rather via the obligatory implementation of revised standards."

That's what a binding lever does. They're just as clear about their limit: standards can still be treated "as a tick-box exercise."

3. Disciplinary precedent: binding by example

This is the rung I want to spend the most time on, because it shows the whole ladder working as a system.

In July 2022, Yuggera, Warrungu and Wiradjuri Associate Professor Kris Rallah-Baker, Australia's first Aboriginal ophthalmologist, received a racist email from a general practitioner. He made a complaint. The regulator investigated and referred the matter to the ACT Civil and Administrative Tribunal. In 2023 the tribunal found the doctor had engaged in professional misconduct, reprimanded him, and disqualified him from applying for registration for twelve months. The tribunal read the code of conduct's clause on discrimination broadly. It rejected the argument that the clause only applied to the workplace.

At the time, the ABC reported it as the first time a tribunal had considered racism and culturally unsafe practice in ruling on professional misconduct under the new laws. Last month, Australian Story described it as the first time a medical practitioner had lost their registration for racist conduct.

Look at the chain behind that outcome.

In 2022, the National Law governing Australia's registered health professions was amended. It gained an objective to build a health workforce that provides culturally safe services to Aboriginal and Torres Strait Islander Peoples. It also gained a guiding principle that the Scheme "contributes to the elimination of racism in the provision of health services." The codes followed the law. The complaint engaged the code. The regulator acted on the complaint. The tribunal had a standard to apply.

And the chain has a starting point people tend to skip. The law didn't change on its own. It changed because a national strategy set out to change it. The National Scheme's Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy produced the shared definition of cultural safety the codes now use, and it made the case for putting cultural safety into the law itself.

The strategy didn't sanction anyone. It didn't need to. It built the lever, the law made it binding, and the regulator used it.

I led the work that put cultural safety into the National Law and built the definition these codes now use. I'll say that once, because the case belongs to Kris. What matters is what it proves: a lever built years earlier, with no particular case in mind, was there on the day someone needed it.

Kris Rallah-Baker has been clear about why the outcome matters beyond his own case:

"For people to see they won't be brought down if they complain about racism, and if they need to reach out, they can."

That's what precedent does. One published decision tells every practitioner in the country where the line is, faster and more credibly than any published commitment could. And it tells every person who has thought about complaining whether it's worth doing. He put the stakes plainly: "Racism in the healthcare system contributes to patient harm and premature death." He also named who the lever is really for: “people who are underprivileged and do not have a voice and not aware of the systems as I am.”

A disciplinary decision is written for the next complainant as much as for the last one.

4. Money: binding by the wallet

This is the rung people are most surprised to see on the list. Regulators don't set practitioners' pay, so it's easy to assume this lever belongs to someone else. It has two faces, and regulators have a hand in both.

The institution. For a hospital, the money lever runs through accreditation. Health services must be accredited to keep operating and keep their funding, and losing accreditation has real consequences. A related form of accreditation shows what losing it looks like. In 2018, intensive care training at Westmead Hospital lost its accreditation over bullying and harassment, and with it the doctors in training the unit relied on. Nobody had to prove a single patient was harmed. The culture was the finding.

Now look at what governments have already signed. The National Health Reform Agreement for 2026–31 commits to embedding cultural safety in the national hospital accreditation scheme. It commits to using pricing to improve "measurement and reporting of racism and cultural safety," and to developing Aboriginal and Torres Strait Islander safety and quality pricing measures. The lever is being built. Whether anyone pulls it is the question.

The individual. Every regulator is also an employer. It decides how its own people progress: whether staff move up a pay increment, what goes into their performance reviews, and, where executives have performance pay, which KPIs that pay depends on. Making cultural safety one of those conditions is an ordinary use of powers the organisation already has.

The same applies to any hospital or health service whose executives have KPIs tied to their pay. Look at what those KPIs already cover: budgets, waiting times, safety incidents, and patient flow. Organisations attach money to what they take seriously. Whether cultural safety is on that list tells you where it actually ranks.

5. Strategies and statements: binding on nobody

On their own, these bind nobody.

That isn't the same as saying they don't matter. The chain above started with one. But a strategy isn't a lever. It's the plan for pulling levers, and its worth depends entirely on how many of them it turns into something binding. A strategy that becomes a law change, a code, a definition and a new governance model has done its job. So has a second strategy that builds on what the first made binding and reaches further. What hasn't done its job is a strategy that replaces the last one with nothing binding in between. That's the same launch, twice.

Nobody has ever been sanctioned for breaching a strategy. The good ones are written so that one day, somebody can be sanctioned for breaching what the strategy built.

Why everyone works the bottom rung

Here's the pattern I keep seeing. Across the sector, the effort is spread in the opposite order to the ladder. Most goes into the strategy, the statement, the action plan and the launch, and too little into turning them into anything binding. Much less goes into codes, standards and conditions. Disciplinary precedent is rarely treated as a cultural safety tool at all. And very few regulators have pointed the pay lever at themselves.

That isn't because anyone chose weakness. It's the same logic as the advisory body I wrote about last month: the bottom rung is the only one that costs the regulator nothing.

The top rungs produce contested decisions. A new registration condition gets consulted on, resisted by professional bodies, and sometimes challenged. An accreditation finding against a university has to be defended. A disciplinary referral means investigation costs, tribunal time, possibly an appeal, and possibly the media. Each of these can fail in public.

A strategy that stays a strategy can't fail in public, because it doesn't commit anyone to anything that could be measured and missed. It produces a launch, a foreword, a set of commitments, and a report that says progress is being made.

So when someone says the system is too complex to act, it's worth hearing what's underneath. Usually it isn't complexity. Every lever that works carries a cost, and the lever with no cost doesn't work.

The individual side of the money rung makes this easiest to see, because it's the only lever that points inward. Every other lever points out at practitioners, providers and complainants. The pay lever points at the regulator's own people. It needs no tribunal, and no profession gets a say. A regulator holds it completely.

Which makes it a clean test. A regulator can require practitioners to meet cultural safety standards as a condition of practice. If it hasn't tied its own staff's and executives' progression to the same standards, it's asking the profession to carry a cost it hasn't accepted itself.

A strategy that never becomes a lever asks nothing of the institution that adopted it. That's what makes it comfortable, and it's why the people who write the strongest strategies write them to be turned into something that binds.

Mandate the conditions. Audit the outcomes.

There's an objection at this point, and it's a fair one: you can't mandate outcomes. Regulators don't control disparities in care. Too many other things drive them.

That's true, and it misses the point. You don't mandate outcomes. You mandate the conditions: the codes, the standards, the education requirements, the consequences. Then you should audit the outcomes to find out whether the conditions are working. Nobody mandates zero surgical infections. They mandate the conditions and publish the rates.

That last step is the one regulation most often skips, and it applies to every rung on the ladder, including the ones I've just praised. A disciplinary decision is meant to change behaviour and lower safety risk to patients, in the practitioner sanctioned and in everyone watching. How many regulators could show you that it did? Whether practitioners who completed cultural safety requirements practise any differently? Whether complaints about racism went up because people felt safer to make them, or down because they gave up?

If we don't know whether our interventions make care safer for Aboriginal and Torres Strait Islander and other First Nations Peoples, we don't know what we're doing. A lever that's pulled and never checked is only one step up from a strategy that's never pulled.

What a cultural safety audit should actually ask for deserves its own article, and it's next.

The map nobody has drawn

Almost every health regulator I know of can tell you what it has committed to on cultural safety and Indigenous-specific racism. Most have published it, and many have published it more than once.

Very few can tell you which levers they actually hold, which of those they've pulled for this purpose, and what evidence shows the ones they've pulled are having any effect.

That's the second map, and it's the one that counts. A commitment tells you what an organisation intends. A lever map tells you what it can do, and what it has chosen not to.

Jurisdictions are starting to move up the ladder. In British Columbia, colleges share a practice standard on Indigenous cultural safety, cultural humility and anti-racism that tells every licensee what they must do. That's the standards lever, pulled across a whole province. What matters next, there and everywhere, is whether the rungs above it get pulled too.

None of these levers is secret. Every one is written into the legislation, standards and employment frameworks regulators already work under. The question isn't whether they exist.

So, how many?

So I'll leave you with the one I'd put to any registrar, board chair or chief executive who has said the system is too complex to change.

Of the levers you actually hold, how many are you using?

If you can answer quickly, you've done something rare. If the question makes you reach for your strategy, ask what it's become. That's where the gap is. It was never complexity.

The next article looks at what a cultural safety assessment should ask for. Get it in your inbox.

Sources

Jayde Fuller
Next

Advisory or Authority: What decides whether Indigenous governance is real