As someone who was embedded in the NHS for a number of years it has many problems, but counterintuitively one of them is actually a lack of paper pushers or at least low level admin and other auxiliary staff.

Because governments have constantly demanded the NHS spend less money, but have also been under pressure to preserve numbers of "front line" staff you've ended up with serious shortages of low level admins, medical secretaries, receptionists, finance officers etc. This means that more and more healthcare workers spend their time doing paperwork or customer service work that could be done by anyone. I worked out of one of the largest genomic diagnostic labs in the country with over 150 clinical geneticists, nurses, scientists and consultants and there were 4 admins. That meant nurses were staffing reception, consultants were managing their own diaries, geneticists were doing stock takes and clinical scientists were packaging up and booking samples onto DHL for collection. This was not an efficient way of working, but the lab had a hard ban on hiring any non "front line" staff. And it had been running like that for years.

The trust as a whole had the same problem on a macro scale. There weren't enough finance officers so invoices didn't get paid or debtors chased (the NHS provides a lot of private services as well). Because of a lack of staff working in recruitment it could take months (4 in my case) between being given a job offer and the paperwork being in place to actually start. Payroll was a nightmare because of lack of staff and multiple unintegrated time recording systems, many of them to this day paper based.

A large number of legacy patient records are still paper based and have to be physically moved around and digitised "on the fly" but because the NHS is supposed to be digital there aren't enough porters payed to literally push the trolleys of records around so you end up with nurses doing it.

I could go on for a long time but you get the idea.

The shift in the western world into paper pushing in healthcare, education, construction, etc doesn't always come in the form of more bureaucrats. Sometimes it's teachers spending time with ever more frequent and granular grading and survey systems, and doctors filling forms for hours a day.

It feels like the McKinsey-style design of large orgs has permeated the public sector just as much if not more than the private one. It always comes with a massive amount of procedure – employee surveys, follow-ups and meaningless 10-scale measurements, so that leadership can rest easy knowing that every decision they make is data driven. Somehow a spreadsheet analyst should be able to diagnose and fix every possible issue in an incremental manner, and conversely, all poor decisions are due to insufficient data.

Yes the demand to have a documented policy, procedure and metrics for everything even if no one ever reads them, follows them or analyses them is insane. At the same time there's been this huge increase in the amount of useless correspondence and a cultural shift away from hiring people to help manage and filter this stuff so people can do actual work (aka old school secretaries and admin assistants). Harrumph

IMHO, every required documentation policy should have its opportunity cost measured against the decrease in actual work being done.

E.g. "Do we think this form being filled out is worth someone not being able to see a doctor?"

Yes it SHOULD be. But the anxious leaders want more data for no other reason than to look at it and think they're more informed, when in reality they are not. It's like being addicted to looking in the mirror. It's good if you can notice the chocolate around your mouth, but more than that isn't helping, it's just a hobby. Only in this case your hobby is destroying everyone else's joy and productivity.

Lack of administrative staff in operations is a mayor problem, pushing paper work to medical staff. Where I live we have the same problem in schools, pushing administration to teachers.

Admin bloat seems to be at a higher level if it exists. Because ordinary secretaries are long gone.

On the other hand, my ex worked for the NHS. To 'solve' the problem of long wait times after check in. They reduced staff at check-in to bottle neck the in flow of checked in patients.

> This means that more and more healthcare workers spend their time doing paperwork or customer service work that could be done by anyone

The obvious solution seems to be reducing the required paperwork rather than hiring more staff to handle the paperwork, and this seems to agree with your experience when you described "unintegrated time recording systems".

That said, I wouldn't be surprised if too much bureaucracy was also partly to blame, because that's what happened here in Canada.

That sounds like exactly the kind of thing you'd say, if you wanted to destroy a beloved public institution though.

Most people are worried about the UK moving to a US model, not to be more like Norway, Netherlands and Australia and administrative efficiency is something the NHS does well:

https://www.commonwealthfund.org/publications/fund-reports/2...

> Conclusion: Four features distinguish top performing countries from the United States: 1) they provide for universal coverage and remove cost barriers; 2) they invest in primary care systems to ensure that high-value services are equitably available in all communities to all people; 3) they reduce administrative burdens that divert time, efforts, and spending from health improvement efforts; and 4) they invest in social services, especially for children and working-age adults.

Austrália isn’t really doing well too , is it ?

I have relatives working in the NHS bureaucracy, even they claim its bloated - there's a fuck tonne of redundancy/duplication of effort and failures to exploit economies of scale, especially in the Trusts system where the same things are replicated dozens of times.

It's the nature of bureacracy. All the incentives are aligned so as not to prioritize efficiency.

This sounds plausible, because it's a story we hear all over the world, again and again. I'm guessing David Graeber's "Bullshit Jobs" has been discussed a few times on Hacker News?

This was such a phenomenon in the seventies that by the time Yes Minister was broadcast the joke was a running ironic theme that met with deflated apathy:

https://duckduckgo.com/?q=yes+minister+hospital+no+patients&...

(Search link because the results are fascinating, looking at Washington hospitals copying British innovation...)

Literally yesterday the Daily Mail published a front page ‘exposing’ the fact that the NHS spends a total of £1 million on diversity. If that’s the best a paper hellbent on attacking the NHS can find, it’s hard to imagine there’s actually much waste.

The Daily Mail has a very anti-immigration and anti-diversity agenda, which fits well into the pro-Tory agenda. That story is a winning combination.

Exploding admin overhead also plagues USA's healthcare. Here's a popular depiction. https://miro.medium.com/max/1376/0*Tw_O22WQs2yyv0ND.jpg

Regardless of private or public, left- or right-wing, bureaucracy begets more bureaucracy. Like a ratcheting effect.

Complaints about bureaucracy is (at least) as old as written history. You may have seen yesterday's frontpage story "The Collapse of Complex Societies (Book Review)" https://news.ycombinator.com/item?id=7207348

Another interesting analysis (for us geeks) is the "complexity catastrophe" described in the book Design Rules: The Power of Modularity. TLDR: Dependencies eventually get so tangled that the cost of change outweighes the expected benefit, and a system which can no longer adapt to the changing world eventually fails outright.

Exploding overhead also happened in education, both K-12 and higher ed. And probably every other mature domain worth examining, if we bothered to look.

Seeing Like a State (James Scott), Bullshit Jobs (David Graeber) and Design Rules (Baldwin, Clark) all address complexity in their own way.

As a geek, I think "path dependent technical debt". For us, there's little to no incentive to cleanup, and certainly no reward, even though everyone moans about it nonstop.

The only notion I have is that, like reducing technical debt, fighting admin overhead (expanding bureaucracy) requires constant effort and investment, that no one is willing to make.

I (greedily) welcome a more optimistic take on this problem, if any one has some ideas. Please.

These days doctors seem to spend more time doing paperwork than actually working.

That's because each of the several hundred billions of pounds of greenfield government software programmes is a slapdash crud forms exercise bugger the millions of man years of development by the original experts despite there's little to change in the vast majority of diagnostic pathways. In fact the Reed Codes which resulted from a immense pan European study of two decades length and became canon in ca 1988 remain canonical the only programming work involved in new processes being parsing these together with inserting a myriad of OR impedence where new forms of graft are inserted. We've just switched off national critical systems of civic function across the board over the past few years. Probate about the most egregious example the replacement system containing a mere handful out of the estimated twenty thousand expert legal assessment rules at inception. Manual operations the only alternative for at least two years that I was paying attention.