Bureaus and bureaucrats create bureaucracy. Together, they build their own demand and transform people into managers designed to meet bureaucratic needs.
A bureau designed to serve patients ends up serving its creators, while protecting those who work inside.
William Niskanen, economist, offered a definition. Roughly speaking, 1) bureaus contain people who do not earn income from the difference between revenues and cost, and 2) bureau revenue does not come from the sale of output per unit rate.
Squeamish About Saying “Bureaucrat”
Many people refuse to discuss bureaus, bureaucrats, or bureaucracy for fear of causing offence. The managerial and chattering classes see talk of bureau-anything as impolite, ill-defined, or perhaps unhinged.
This tactic is old. See Orwell’s, 1984. Control language; control the masses.
Forcing a word out of fashion does not remove the reality it described. Changing labels creates an endless need for new labels. Relabelling bureaucracy as management or administration does not escape the need to debate the concept.
We need bureaucracy, just like we need surgery. Surgery saves lives when nothing else will do. At the same time, there is nothing that surgery cannot make worse.
The Need for Bureaucracy
As organizations grow, they build bureaus and bureaucracy to decrease risk. Bureaucracy exists to slow things down and make us think twice.
For example, hospitals create communications departments to decrease the likelihood of bad press. Government funding relies foremost on keeping funders happy. Bad press about patient care trumps concern over care itself.
Every element of service creates its own demand for bureaucratic process.
Forms, checklists, and audits.
Computer passwords, authentication, password expiry, and mandatory sign-off.
HR credentialing… the list is endless.
Room always exists for more bureaucracy, with its imprimatur of orderliness and excellence.
The Value of Bureaucracy
Organizations and governments build teams of professional managers (bureaucrats) at significant cost.
Teams struggle to justify their own expense. They cannot point to profit or improved patient care. Given fiscal austerity, ballooning bureaucratic budgets make managers cringe in anticipation of scrutiny.
This creates an impassioned hunt for confirmation of value. Bureaucrats need something — anything — to prove their worth.
They create committees, collect surveys, redesign org charts, and perform market scans. Too often, they collect affirmation, not information.
Confirmation of current work trumps data indicating need for change. They are the antithesis of the entrepreneurial thesis.
The size of a bureaucracy serves as a surrogate for value — especially amongst fellow bureaucrats. Professional bureau managers focus on inputs, not outputs. Activity trumps accomplishment.
Size and scope of services mean little to the bureaucrat, aside from indicating the need for more bureaucracy.
A bad quarter suggests a lack of bureaucratic oversight.
Increased patient volumes produces a smaller bureaucracy-to-service ratio. This demonstrates a need for more bureaucracy.
Bureaucracy and Patient Care
If patients have nowhere else to go, then organizations tend to pursue endless exercises of self-congratulation to ‘prove’ their worth.
Managers struggle to maintain a positive view of patients. Patients become threats to otherwise good performance data.
Life would be great if it weren’t for all the patients.
Better Bureaucracy
No organization of any size can escape bureaucracy. Given that fact, what can be done?
Limit the Dose
Treat bureaucracy like dynamite or digoxin (a heart medication). Each serves a purpose when nothing else will do. But dosage matters. Neither one should be the only tool for every job.
Consider a 10:1 ratio for new bureaucrats. Hire at least ten workers, nurses, or technicians for one manager.
Dilute the Impact
Ideally, bureaucrats should work part-time. They need to participate in practical service delivery. Managers should help with patient care, in whatever way their training allows.
The fact that this point might sound outrageous indicates the depth of our devotion to bureaucracy and bureaucrats.
Imagine an MBA portering a patient or spending a few hours delivering meals to patients warehoused in hallways? Absurd.
How could an executive ever spend time waiting to offload an ambulance stretcher? Outrageous.
An organization will waste more from inefficiency created by bureaucracy than from having bureaucrats see how bureaucracy slows service delivery.
Choice
In service industries, quality hinges on customer experience. This is notoriously difficult to measure. Patients know when they got lousy care, but it will not register on a survey.
Service never survives as the primary concern, if customers cannot exit. We must let people leave.
Monopoly is anathema to quality – especially in times of fiscal austerity and low staff morale.
If patients have no choice but to come to you for service or care, then you have no idea what they really think. Patients know that their complaints could compromise current care.
Choice drives quality. Choice assumes the chooser knows enough to decide what is best. Bureaucracy assumes the bureaucratic designer knows best.
Promotion
The Net Promoter Score (NPS) is the next best option, after choice. It asks, How likely are you to recommend this service to someone else?
It is a brutal score. CEOs hate it. They only embrace an NPS to offset greater risk or criticism.
The NPS analogue for a staff survey is: How likely are you to fight to keep your colleague on the team, if senior management were trying to fire him?
Necessary But Never Harmless
Bureaucracy begets more bureaucracy. It creates an endless need for more bureaucrats, and it ends up serving itself.
Bureaucracy is necessary but dangerous. It pulls limited clinician resources away from patient care.
We need a frank discussion about bureaucracy and patient care. If we do not find ways to cut back and limit the growth of bureaucracy, patient care will continue to struggle for attention.
Photo credit: Pixabay
As always I enjoy your commentaries. When I was a consultant, now retired from clinical practice in a teaching hospital, a bit of an oxymoron when large bureaucracies were prominent, I used to say that the hospital would be just as busy and maybe even busier if there were no patients. This would mean more managers having more meetings, with the same agenda and outcome. Don’t get me wrong, they are a necessity for some things, and some wonderful people, but your idea of getting them involved in the day-to-day care of patients is excellent. We occasionally had a CEO who used to visit every ward, clinic and ICU but they generally did not last long, as you might expect.
Also said at 4PM in such a large hospital, I joked that one could shoot a cannon down the corridor and not hurt another human being. People are just GONE! It makes it easier to get around and see patients and work but it is an eerie phenomenon for sure! Also one cannot stereotype as there are some excellent people in the bureacracy who know what to do and have done it but they get lost in the maelstrom.
Fantastic comments, Allan. I agree with them all!
“I used to say that the hospital would be just as busy and maybe even busier if there were no patients.” Love this line.
Yes, we have many fantastic, smart, talented, experienced people working in bureaucracy. If only life were so simple that we label and dismiss everyone in management.
I worry that outstanding people working as administrators/managers/bureaucrats do not have the time to invest in what they know to be valuable. I am certain that many would love to work as a porter in the ICU once a month. What responsibilities would they have to give up in order to squeeze a non-bureaucratic item into their schedule?
Really appreciate you posting this! Thanks so much
Cheers
Holy JUMPIN’
I thought that was just me…as I booked client appointments at the end of the day thinking it would be ‘quieter’ in the clinic/lab. As of last week one can still fire a cannon-ball down the hallways at large tertiary care institutions and not hit a soul (at 359p). When I was a bureaucrat through the 90’s, I must say my area had a rather dedicated bunch that soldiered on until the lab was clear – and no we were not suckers! Maybe just a different work ethic.
Ha! Thanks for this, Rickk
After hours, everything changes. Workers get left alone and can finally work to complete task instead of working to adhere to administrivia.
” I used to say that the hospital would be just as busy and maybe even busier if there were no patients” Watch this:
https://youtu.be/x-5zEb1oS9A
Classic series!
Good afternoon Shawn
I was very slow to make a posting on your last “Blog” and this time I am bit quicker to do so. I always enjoy them and usually agree in general with your comments. This time I do as well but don’t know why what you say, actually happens. I do understand that a left wing society often starts to collapse under the weight of bureaucracy and the “more left” the more quickly it happen.
Years ago the President of the Canadian Society of Vascular Surgery in his farewell address at the conclusion of his presidency, talked about his Hospital in London Ontario. The following numbers are not exact but close enough for Government work. When he started the hospital had 1,000 beds and 8 administrators and when he gave his address 30years later the hospital had 500 administrators which was one per patient bed. How things change. His tenure started approximately the same year that the Government took over administration of health care (1969).
Wow — fantastic details, Graeme. These are golden.
“The following numbers are not exact but close enough for Government work. When he started the hospital had 1,000 beds and 8 administrators and when he gave his address 30years later the hospital had 500 administrators which was one per patient bed.”
I think bureaucracy is a bi-partisan passion. All parties seem to love it.
We seem to have entered the epoch of managerialism just after WWII (some say it started earlier). Managerialism promotes the idea that expert managers do a better job at running everything, and that we should expand management as much as possible.
Managerialism = management + expansionism.
(See Burnham’s The Managerial Revolution, 1941)
Thanks again for taking time to share your experience. Again, this firsthand knowledge is extremely powerful. It’s the only way to challenge a popular paradigm.
Cheers
I am led to believe that the Ontario Ministry of Health has 11,000 people doing pensionable time. What do they do all day? Can we not get rid of half or 5,500 by attrition and still get the same result? Probably take 4 or 5 years using the attrition method.
Great question.
Andre Picard, journalist with the Globe and Mail, reported that Ontario has 13,000 health bureaucrats in 2018: https://spon.ca/doug-ford-needs-to-rein-in-ontarios-bureaucratic-health-care-mess/2018/06/26/
I believe Picard’s estimate was conservative.
I’m not sure we can get rid of them until we offer cover/medicolegal protection for people working inside the system. Bureaucracy gives something people can point to when bad things happen to patients. If you can say, Look … I was only following protocol, you are safe.
In other words, we have to get rid of the need for bureaucracy before we could achieve the 50% reduction you suggest. I love it, by the way.
Thanks for posting!
Great post Shawn.
I have been going on about this for many years.
When I started my practice in 1991,our hospital had 1 VP.
Now,it has 20 VP’s and 17 assistant VP’s !!!
Germany has 10 times fewer med system bureaucrats than Canada.
We desperately need a European hybrid system.
Wow. It’s a growth industry!
Sure appreciate you sharing these figures, Ram, and your call for a hybrid system. We need hundreds of similar stories to get people to, maybe, consider change.
Great to hear from you — hope you are well!
Cheers
“We need a frank discussion about bureaucracy and patient care. If we do not find ways to cut back and limit the growth of bureaucracy, patient care will continue to struggle for attention.”
I think your last sentence is an apt description of what ails us regarding bureaucracy and its role in the provision of health care.
I liken this whole situation to climate change and energy transition and use that metaphor in discussion with others.
Overshoot means that humans are using natural resources (substitute health care dollars) at rates beyond the planet’s (substitute Province of Ontario) capacity to recover.
The effect of human activities (substitute bureaucracy) on the atmosphere and ecosystem (substitute health care system) cannot be solved through energy substitution (substitute all kinds of plans by Ontario’s health care bureaucracy-except for user fees of course).
This can only be addressed by using less energy. However, modern day economic theory revolves around the concept of perpetual growth (increase the number of middle managers and their budgets). The real energy transition is a REDUCTION in energy use. I understand that this is not palatable to most of us, but we will have to deal with “the limits to growth”.
I concede that it’s a poor comparison, but it’s the best I can do to wrap my head around what in my amateur opinion is the nearly impossible task of starting to create a completely new paradigm where we can begin to, in your words, “cut back and limit the growth of bureaucracy”.
Unfortunately, this will NEVER happen voluntarily. It’s despairing to say the least.
As I noted in a previous comment, any trend that is eventually destined to end will in fact do so. Trend changes can be particularly painful for the unprepared.
Thanks for the blog.
Fascinating comments, David.
“…we will have to deal with “the limits to growth”.”
I was just discussing this with a colleague yesterday. He mentioned Harari, author of Sapiens, and how Harari suggested we need to start asking ourselves about progress. Do we need more? If so, what are we hoping to achieve?
On one hand, this has been used as a core, anti-capitalist creed. The Left loves this kind of thinking.
However, we should consider how the thinking behind the pursuit of more-better-cheaper animates, in part, the continual pursuit of more bureaucracy. I suspect the desire for more bureaucracy comes from the desire to control and not just progress to more and more and more. But I take your point, we should note the similarities.
I also take your point about it not happening voluntarily. This is undoubtedly true for any particular organization in question.
However, I think we will see more examples of people bypassing the bureaucratic/regulatory bloat. For example, patients will increasingly opt to purchase point-of-care technology to find out lab results on their own at home. Tech improves so fast that the regulatory state will struggle to keep pace — there will always be a new, unregulated tech for patients to adopt on their own.
As patients continue to leapfrog organizations shackled by bureaucracy, the bureaucratic state will atrophy as its host continues to wither.
This is my version of a voluntary decrease in bureaucracy brought about by the death of bureaucracy’s host.
Big changes ahead … I predict. 😉
Cheers