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Doctors - and other professionals - have complained about bureaucracy throughout history[1]. Analogy suggests that bureaucratic processes will evolve towards stagnation[2]. Bureaucratic reform is often promoted by politicians, indeed it may be the hallmark of populist politicians. There is good evidence that badly designed bureaucratic systems have a net negative effect on healthcare efficiency[3][4], patient safety[5] and clinical knowledge[6][7]. Well designed processes, that some doctors would regard as bureaucratic such as an informatics tool that detected high risk prescribing, can however be very effective[8].

In a medical context, bureaucracy may be considered work, often administrative work, done for purposes which relate to organisational processes, rather than direct patient care.

Often bureaucratic processes are set up for good reasons; but without clear systems for ensuring that they are really necessary and worthwhile, bureaucratic tasks can increase until they have a severe impact on a professional's ability to do the tasks that their professional training makes them capable of. The regulation of health services - including eg checks that hospitals are meeting their targets - is a considerable and costly burden.[9]

Many of the requests from patients instructed to Get a note from your doctor are driven by bureaucracies - frequently not from the organisation within the doctor works.

Bureaucracies report on other bureaucracies and the HiT series of reports from WHO[10] is essential reading for those who wish to understand comparative healthcare.

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With current (2015 onwards)[11] pressures on healthcare, with health care funding failing to keep up with health sector inflation (or suffering cuts, known as "efficiency savings" in Whitehall's Orwellian newspeak; and increased pressures from the development of medical science and the ability to do more, an ageing population, and cuts to social care (which impact on health care), fighting bureaucracy is as important as ever.[12]

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The Canadian Healthcare system was reviewed in 2013 [13]

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The Australian Healthcare system was reviewed in 2006[14]

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The New Zealand healthcare bureaucracy was reviewed in 2014[15], it having been noted in 2006 that District health board bureaucrats have increased in number by 23%[16]

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The American healthcare system was reviewed in 2013[17]

Many of the documents which can be used to deflect inappropriate requests are provided in ganfyd's Get a note from your doctor page.

External links


  1. Patel K. Bureaucracy holds the NHS back. BMJ (Clinical research ed.). 2013; 347:f4624.(Epub)
  2. Charlton BG. The cancer of bureaucracy: how it will destroy science, medicine, education; and eventually everything else. Medical hypotheses. 2010 Jun; 74(6):961-5.(Link to article – subscription may be required.)
  3. Himmelstein DU, Woolhandler S, Wolfe SM. Administrative waste in the U.S. health care system in 2003: the cost to the nation, the states, and the District of Columbia, with state-specific estimates of potential savings. International journal of health services : planning, administration, evaluation. 2004; 34(1):79-86.
  4. Johnsen H. Professional responses to post bureaucratic hospital reforms and their impact on care provision. Women and birth : journal of the Australian College of Midwives. 2015 Jun; 28(2):e19-25.(Link to article – subscription may be required.)
  5. Schmidt PJ. Blood, AIDS, and bureaucracy: the crisis and the tragedy. Transfusion medicine reviews. 2011 Oct; 25(4):335-43.(Link to article – subscription may be required.)
  6. Califf RM. Clinical trials bureaucracy: unintended consequences of well-intentioned policy. Clinical trials (London, England). 2006; 3(6):496-502.(Link to article – subscription may be required.)
  7. Wolinsky H. B for bureaucracy. EMBO reports. 2010 Sep; 11(9):664-6.(Link to article – subscription may be required.)
  8. Dreischulte T, Donnan P, Grant A, Hapca A, McCowan C, Guthrie B. Safer Prescribing - A Trial of Education, Informatics, and Financial Incentives. The New England journal of medicine. 2016 Mar 17; 374(11):1053-1064.(Link to article – subscription may be required.)
  9. Edwards N. Burdensome regulation of the NHS. BMJ 2016;353.
  10. Health Systems in Transition (HiT) WHO European Observatory on Health Systems and Policies
  11. HiT UK WHO 2015
  12. Roland M, Everington S. Tackling the crisis in general practice. BMJ (Clinical research ed.). 2016; 352:i942.(Epub)
  13. HiT Canada WHO 2013
  14. [http://www.euro.who.int/__data/assets/pdf_file/0007/96433/E89731.pdf HiT Australia WHO 2006
  15. Cumming J, McDonald J, Barr C, Martin G, Gerring Z, Daubé J. New Zealand Health System Review Health Systems in Transition 4(2) 2014
  16. NZ herald
  17. HiT USA WHO 2013
  18. Cabinet Office Public Sector Team. Reducing General Practitioner (GP) Paperwork, 2001 (March).
  19. Price C. GPs fear new hospital discharge guidance will lead to workload dump. 2016; Updated 17 March 2016; Accessed: 2016 (18 March).
  20. Pulse. "Say 'NO!' to inappropriate requests with our template letters". 2016 (June 16). (Last viewed 23 June 2016)

This article is a work in progress. Please feel free to contribute to it.