Misery, Thy Name Is Bureaucracy

It has been said that you can judge a nation by the way it treats its most vulnerable citizens. By that standard, Great Britain deserves little in the way of accolades. The nation embraced a socialized medicine program in 1948 known as the National Health Service (NHS). It is a monopoly in every sense of the word. Functionaries at various levels of an impossibly large and impenetrable bureaucracy make all decisions of health care access, methodology, and technology.

As is true of any bureaucratic organization, there is a tendency to abandon the purpose of the process and to become obsessed with the process itself. Vast resources are arrayed to study the existing processes, inevitably resulting in a framework of new processes that seek to guide the processes upon which they are layered, accomplishing nothing more than to provide an excuse for the bureaucracy to grow and consume ever-greater resources. It is not long before the bureaucracy reaches the tipping point and becomes a self-replicating machine. As Ronald Reagan famously said,

No government ever voluntarily reduces itself in size. Government programs, once launched, never disappear. Actually, a government bureau is the nearest thing to eternal life we'll ever see on this earth!

The NHS in Britain is just such a machine. Layer upon layer of administration has eclipsed the direct-care personnel. The ratio has tilted precipitously towards the paper-pushers while the front lines of physicians and nurses collapse under the weight of regulation and diminished funding. How does an organization that consumes approximately 10% of a nation's gross domestic product suddenly find itself so short on cash that patients are literally dying as a direct result of poor conditions?

Stafford Hospital in Staffordshire, England is an example. A retired government risk assessor had been asked by a patients' group to examine the feasibility of installing bedside telephones for the patients. Once you get past the fact that there exists a hospital in a major industrialized nation such as Great Britain that does not already have bedside telephones for patient use, it is instructive to note the conditions the risk assessor found as he moved about the building. In the emergency room waiting area were chairs with "congealed blood smeared on torn cushions." A general filth could be seen, from the grimy floors to the sinks encrusted with God-knows-what. These are the same sinks used by doctors and nurses to wash up before procedures. Restroom floors were covered in urine-and-feces-soaked bathroom tissue. 

A more comprehensive listing of the squalid conditions may be found here

More compelling is the brusque behavior that passed for medical care at this facility. Patients went for hours without pain medications, screaming and crying to no avail. Food service consisted of placing a tray in the general vicinity of the patient's room, whether the patient was able to feed himself or not. Family members of patients frequently took the bedsheets home to launder -- because the hospital would go weeks, sometimes months, without providing fresh linens, even after a soiling accident by the patient. Those patients not fortunate enough to have regular visits from loved ones often lay in their own waste for weeks at a time, resulting in infections and secondary diseases.

Of course, the NHS is not entirely indifferent to the concerns of patients and their families. They have kindly provided a very simple and effective complaints process, which I have provided below, taken directly from the website of the Stafford Hospital itself.

                          COMPLAINTS PROCESS

                            (current - October 2009)

1  Contact from complainant made with/sent to Customer Services team  (eg. verbal, letter, email etc)

2  Customer Services team prepare the ‘case'  (eg. access medical records, asses risk and give score, input onto Safeguard computer database system)

3  Customer Services team contact the complainant verbally (must do within 3 working days) and understand/agree:

     - issues to be addressed

     - what outcome they seek

     - time for resolution (no maximum time set)

     - whether they wish to meet

4  Customer Services team issue ‘agreement letter' to complainant (incl. where appropriate meeting arrangements if confirmed at that stage)

5   Customer Services team issue documentation to relevant Divisional Customer Complaints coordinator for review - investigation (where written response requested by complainant)

6. Division provide statements/responses (if a written response is required) to the issues raised and forward these to the customer services team

7. Customer Services team draft response to complainant and send to Division for approval

8  Division confirm approval to Customer Services team

9  Customer Services team draft final version to CEO for signature

10 Customer Services team send approved response to complainant (and copy Division)

11 Customer Services team complete the data on the safeguard database and close the file.

Obviously, such a finely honed process would be capable of responding to issues in a manner having more in common with molasses than lightning. In fact, the process worked so well that it took an eye-popping spike in mortality rates at the hospital to trigger anything more than a polite response letter pledging to "maintain the highest standards of care" before the NHS initiated an actual investigation. The result? The Health Commission investigation discovered that "between 400 and 1200 patients died prematurely" due to the conditions and lack of care at the Stafford Hospital. This is not surprising when one considers that heart monitors in the "emergency assessment unit" were turned off because the nurses didn't know how to use them.

The NHS has laid the blame at the feet of that reliable shibboleth, "lack of funding." In this case, it is accurate, but not for the reasons given by the NHS; although the funding for the NHS has grown by 300% in the last twelve years, the funding for actual patient care has been dwindling as the bureaucracy elevates redundancy to an art form, using up a greater share of the available funds and truly becoming a self-replicating machine obsessed with process over purpose.  The British health care bureaucracy created a "checklist culture" so far removed from the underlying animating principles as to have become actively indifferent to the suffering it caused.

This is the nature of bureaucracies. They are present at every level of government, from top-heavy fire and police unions that hold the cities they serve hostage for outsized pension and health benefits to county, state, and federal divisions engaging in the building of fiefdoms and empires that, once constituted, are nearly impossible to dismantle -- a task made infinitely more difficult by the explosion in growth of public employee unions. 

Few of us have been spared the experience of dealing with one of these process-obsessed bureaucrats at one time or another. Such encounters are the very definition of frustration, as our attempts at reason are thwarted at every turn by yet another form to fill out or hoop through which we are obliged to jump. 

How much greater will that frustration be when the life of a loved one is involved? Call your congressman and senators. Write them letters and insist that they preserve the greatest health care system in the world. Your family's very lives may one day be at stake. Just ask the British; they know all too well.

Joe Herring writes from Omaha, NE and can be reached at readmorejoe@gmail.com.
It has been said that you can judge a nation by the way it treats its most vulnerable citizens. By that standard, Great Britain deserves little in the way of accolades. The nation embraced a socialized medicine program in 1948 known as the National Health Service (NHS). It is a monopoly in every sense of the word. Functionaries at various levels of an impossibly large and impenetrable bureaucracy make all decisions of health care access, methodology, and technology.

As is true of any bureaucratic organization, there is a tendency to abandon the purpose of the process and to become obsessed with the process itself. Vast resources are arrayed to study the existing processes, inevitably resulting in a framework of new processes that seek to guide the processes upon which they are layered, accomplishing nothing more than to provide an excuse for the bureaucracy to grow and consume ever-greater resources. It is not long before the bureaucracy reaches the tipping point and becomes a self-replicating machine. As Ronald Reagan famously said,

No government ever voluntarily reduces itself in size. Government programs, once launched, never disappear. Actually, a government bureau is the nearest thing to eternal life we'll ever see on this earth!

The NHS in Britain is just such a machine. Layer upon layer of administration has eclipsed the direct-care personnel. The ratio has tilted precipitously towards the paper-pushers while the front lines of physicians and nurses collapse under the weight of regulation and diminished funding. How does an organization that consumes approximately 10% of a nation's gross domestic product suddenly find itself so short on cash that patients are literally dying as a direct result of poor conditions?

Stafford Hospital in Staffordshire, England is an example. A retired government risk assessor had been asked by a patients' group to examine the feasibility of installing bedside telephones for the patients. Once you get past the fact that there exists a hospital in a major industrialized nation such as Great Britain that does not already have bedside telephones for patient use, it is instructive to note the conditions the risk assessor found as he moved about the building. In the emergency room waiting area were chairs with "congealed blood smeared on torn cushions." A general filth could be seen, from the grimy floors to the sinks encrusted with God-knows-what. These are the same sinks used by doctors and nurses to wash up before procedures. Restroom floors were covered in urine-and-feces-soaked bathroom tissue. 

A more comprehensive listing of the squalid conditions may be found here

More compelling is the brusque behavior that passed for medical care at this facility. Patients went for hours without pain medications, screaming and crying to no avail. Food service consisted of placing a tray in the general vicinity of the patient's room, whether the patient was able to feed himself or not. Family members of patients frequently took the bedsheets home to launder -- because the hospital would go weeks, sometimes months, without providing fresh linens, even after a soiling accident by the patient. Those patients not fortunate enough to have regular visits from loved ones often lay in their own waste for weeks at a time, resulting in infections and secondary diseases.

Of course, the NHS is not entirely indifferent to the concerns of patients and their families. They have kindly provided a very simple and effective complaints process, which I have provided below, taken directly from the website of the Stafford Hospital itself.

                          COMPLAINTS PROCESS

                            (current - October 2009)

1  Contact from complainant made with/sent to Customer Services team  (eg. verbal, letter, email etc)

2  Customer Services team prepare the ‘case'  (eg. access medical records, asses risk and give score, input onto Safeguard computer database system)

3  Customer Services team contact the complainant verbally (must do within 3 working days) and understand/agree:

     - issues to be addressed

     - what outcome they seek

     - time for resolution (no maximum time set)

     - whether they wish to meet

4  Customer Services team issue ‘agreement letter' to complainant (incl. where appropriate meeting arrangements if confirmed at that stage)

5   Customer Services team issue documentation to relevant Divisional Customer Complaints coordinator for review - investigation (where written response requested by complainant)

6. Division provide statements/responses (if a written response is required) to the issues raised and forward these to the customer services team

7. Customer Services team draft response to complainant and send to Division for approval

8  Division confirm approval to Customer Services team

9  Customer Services team draft final version to CEO for signature

10 Customer Services team send approved response to complainant (and copy Division)

11 Customer Services team complete the data on the safeguard database and close the file.

Obviously, such a finely honed process would be capable of responding to issues in a manner having more in common with molasses than lightning. In fact, the process worked so well that it took an eye-popping spike in mortality rates at the hospital to trigger anything more than a polite response letter pledging to "maintain the highest standards of care" before the NHS initiated an actual investigation. The result? The Health Commission investigation discovered that "between 400 and 1200 patients died prematurely" due to the conditions and lack of care at the Stafford Hospital. This is not surprising when one considers that heart monitors in the "emergency assessment unit" were turned off because the nurses didn't know how to use them.

The NHS has laid the blame at the feet of that reliable shibboleth, "lack of funding." In this case, it is accurate, but not for the reasons given by the NHS; although the funding for the NHS has grown by 300% in the last twelve years, the funding for actual patient care has been dwindling as the bureaucracy elevates redundancy to an art form, using up a greater share of the available funds and truly becoming a self-replicating machine obsessed with process over purpose.  The British health care bureaucracy created a "checklist culture" so far removed from the underlying animating principles as to have become actively indifferent to the suffering it caused.

This is the nature of bureaucracies. They are present at every level of government, from top-heavy fire and police unions that hold the cities they serve hostage for outsized pension and health benefits to county, state, and federal divisions engaging in the building of fiefdoms and empires that, once constituted, are nearly impossible to dismantle -- a task made infinitely more difficult by the explosion in growth of public employee unions. 

Few of us have been spared the experience of dealing with one of these process-obsessed bureaucrats at one time or another. Such encounters are the very definition of frustration, as our attempts at reason are thwarted at every turn by yet another form to fill out or hoop through which we are obliged to jump. 

How much greater will that frustration be when the life of a loved one is involved? Call your congressman and senators. Write them letters and insist that they preserve the greatest health care system in the world. Your family's very lives may one day be at stake. Just ask the British; they know all too well.

Joe Herring writes from Omaha, NE and can be reached at readmorejoe@gmail.com.