Bureaucracy and Medicine, an Unholy Marriage

Bureaucracy

It is said that every people has the Government it deserves. It is more to the point that every Government has the electorate it deserves, for the orators of the front bench can edify or debauch an ignorant electorate at will. Thus our democracy moves in a vicious circle of reciprocal worthiness and unworthiness (G. B. Shaw in Heartbreak House).

Bureaucracy dates back to ancient societies across the globe. Indeed most of the written documents of the Sumerians and Babylonian kingdoms contain tedious lists of the goods delivered to the temples or to the rulers. According to the Encyclopaedia Britannica, bureaucracy is defined as “professional corps of officials organised in a pyramidal hierarchy and functioning under impersonal, uniform rules and procedures. In the social sciences, the term usually does not carry the pejorative associations of popular usage”.

The French economist Marquis Jacques Claude Marie Vincent (1712–1759) was probably the first one to use the word “bureaucracy” to define and criticise the cast of the powerful employees of the French Government. In 1890 Max Weber studied and popularised bureaucracy [1]. In 1957 Sir C. N. Parkinson [2] discussed the bureaucratic administration of the British marine, offered a mathematic formula to calculate the effects, and created the famous bureaucratic rules: number 1: every employee wants to increase the number of dependents, but not to increase the number of potential rivals; number 2: employees produce work for other employees. Parkinson proved that the yearly increase of administrative employees was between 5.2 and 6.6%. Citizens of modern societies will have noticed the long-term, progressive growth and spread of bureaucracy which infiltrates all forms of social organisation. According to Charlton [3] bureaucracy is similar to a metastasising cancer with an uncontrollable growth. He writes: modern bureaucracies have simultaneously grown and spread in a positive-feedback cycle; such that interlinking bureaucracies now constitute the major environmental feature of human society which affects organisational survival and reproduction. Individual bureaucracies must become useless parasites which ignore the ‘real world’ in order to adapt to rapidly-changing bureaucratic reality. The costs of bureaucracy are enormous. In Switzerland in 2008, 260 000 bureaucrats were counted, and in 2011 the administrative costs were estimated to be about 65 CHF billion [6]. These costs ought to be compared to the spending in other social systems. This is unlikely to happen, because the government, which has created the bureaucratic system, has no interest to let the message be known and the data can only be found in rare and specialised papers.

Bureaucracy, control of medical quality and medicine

Medicine is not out of the world and has been reached by bureaucracy. Bureaucrats assert that the system is necessary to allow “evaluation” and “improve quality”. In theory there should be no objection. Therefore, the “quality control” of medicine has been introduced in most countries and keeps expanding in spite of inefficiency and deleterious consequences.

In USA the bureaucracy of the health care system consumes a large share of health spending. In 1983 the administrative costs of the Medicaid and Medicare Program were USD 2.9 billion, the nationwide administrative costs were USD 26.9 billion (18.3 percent of hospital care) and the administrative costs of nursing homes were USD 4.1 billion [4]. The costs have increased more than the inflation rates and, in 1999 administrative costs consumed at least 31 percent of health spending [5]. In a recent TV survey it was stated that in USA a generalist from Florida must see 33 patients per day to cover the cost of the administrative system, and only with the 34th patient he starts earning his money. The financial burden of bureaucracy is similar in Switzerland.

The USA bureaucratic mindset is the outgrowth of a kind of terminal hubris that imagines those who create and enforce the rules as the only stakeholders worthy of any respect [7]. Whenever someone is scheduled for an operation the nurse is required to fill out a “pre-OP checklist” to ensure that all safety and quality metrics are being adhered to; before the patient is allowed to be wheeled into the OR one makes sure that the surgical site is marked, the consents are signed, all necessary equipment is available etc. [8]. As a consequence, doctors vanish from view harried by the bureaucracy of medicine; physicians are pulling back from patient care [9]. All physicians are unanimous that the “quality control” has not increased the quality in medicine but has frustrated the working physicians (time loss with useless paper writing) and has created a huge increase in the professional costs [10]. This is proven true, because in spite of administrative restrictions and loss of time at least 30 percent of the health costs in USA and Switzerland are still due to ineffective and possibly dangerous therapies [11].

Perhaps worse, quality controls have forced Swiss hospitals to engage in many defensive activities and have dissatisfied the personnel [6]. To satisfy “TARMED” (the Swiss system for medical invoicing) physicians and nurses must codify every action, count the minutes of activity and consider the technical activity (instruments / room use). A lot of paper must be produced. The insurance companies request to “justify” why a diagnostic assessment or a therapy was offered. Physicians must also describe comorbidities and give personal diagnoses of their patients to the insurance companies. Physicians and nurses are thus forced to spend more time with “administrative” activities rather than treating patients and their life is dominated by Excel, PowerPoint, beamer and controller. In the about 500-bed Waidspital (hospital) near Zurich this task produces 100,000 pages of paper per day [6]. Considering the expenses of the studies and qualifications of the hospital personnel the time they spent with administrative work and bureaucracy (rather than working with patients) is too expensive.

Another aspect is due to the fact that videocracy (German: Mediokratie) is now dominating the science and medicine [12]. Self-appointed “experts” are supported from medical insurances and involved politicians. In seminars, workgroups, journal and TV reports they present the advantages of the actual bureaucratic system and claim that quality control in medicine has already began to reduce resource misallocation and wrong decisions. It is proven that this is not true [10,11]. One could quote G. B. Shaw who wrote “he who can, does; he who cannot, teaches”.

Severe restrictions in the practice of medicine were initially correct, but too much has been deleterious. Now the medical profession is only possible with certifications, courses, guidelines, ethical rules, legal institutions, and dictates from the social insurances. The bureaucracy is more and more oppressive and the paper work is more important than proven good experience and talent. This brings a loss of time, hinders innovation and has created a diffuse distrust which is not an incentive for a good professional work [10,12].

The loss of medical professionalism is one thing. The economic restrictions are another aspect. Physicians only get paid by the minute with the patient and by limiting the therapy. Managed care models make the less “expensive” physician the best of the group [10,12,13]. In hospitals chemists and engineers are absent, but we have too many lawyers, economists and experts in communication [14]. The life of a human being is valued as CHF 100,000, no more, no less [15]. The discussion about the medical cost of a life is outrageous and the value of the success of the medicine is not even mentioned: hundreds of thousands of people owe their health and the possibility of working to the medical progress, they produce brain activities and goods which can be sold and contribute to the economics of the country, and indeed, after Japan, Switzerland is the country with the greatest longevity in the world [16]. Of course physicians must (and do) consider the cost of medicine, but the endless burden of bureaucracy and administration must be reduced, because medicine is not a “business” [10,16].

Conclusions

The costs of bureaucracy and the number of bureaucratic dictates should be reduced to the absolute necessary, rather than being unlimited and continuously increasing. Qualified non-medical personnel should deal with bureaucratic codes and the reasonable, numerically limited requests from medical insurances. Nurses and physicians have other qualifications, duties and responsibilities. The costs would also be reduced. If this is not going to happen, medicine will face a somber future, the health expenses will increase indefinitely with a parallel decrease of professionalism and a reduction in the quality of the medical treatment. We will have plenty of administrative statistics and “experts” in economics and theories, but we will be short of professionals.