Sean Roche: Is excessive bureaucracy unethical?

sean_rocheIn subjecting the bureaucratic machine underpinning the NHS to ethical scrutiny, I suggest that we adhere to a basic premise: that it is ethically incumbent on a public health service to maximise the health and wellbeing of the population, within the constraints of the finite resources at its disposal.

In my view we currently fall far short of this imperative. A major obstacle is what I would describe as a “fetishization” of data, and the subsequent procedures for collecting it. In my specialty, psychiatry, there has been an alarming escalation in demands for various kinds of data to be collected and entered by clinicians who could be more profitably occupied by actually seeing patients in a therapeutic context. One driving force behind data-mania derives from an overly zealous Department of Health and local commissioners who need hard statistical evidence that they are getting value for money. “Payment by results” has brought a gamut of new scores and ratings of patients in order to render the market transaction between purchaser and provider smooth and transparent. Now, I am fully supportive of the intelligent use of data in the optimization of quality care, but I believe we have now exceeded a tipping point beyond which data-mania becomes wasteful, counterproductive, and violates our basic premise. In a word, unethical.

It is now commonplace in psychiatry that a clinician will spend more time entering information after a consultation than they spend with the patient. Commissioners fail to grasp an essential paradox. In order to be assured of “value for money,” they demand that ever more information be collected as “evidence” of an (effective) intervention. But in so doing, far fewer patients will be seen in a timely way. Commissioners end up shooting themselves in the foot. There’s an inevitable trade-off between time devoted to collecting and entering data, and time spent in therapeutic activites.

There are other ways in which data-mania results in unethical behavior. In data-obsessed systems, patients are increasingly conceived as abstract data sets. In psychiatry they are numerically rated and assigned “clusters” that determine subsequent care pathways. A referral to a treating team can be declined because a data field is incomplete. There follows a delay whilst the offending clinician rectifies a minor administrative error, in order for the referral to be accepted. But it cannot be justified for a patient to endure extended illness because a bureaucratic system is intolerant of administrative glitches. The danger arises when a system views patients as so many data-fields rather than as individuals. Moreover, distressed and vulnerable patients can feel badgered by data-oriented clinical encounters: How many hours do you work? Give up smoking (however distressed you’re feeling right now)? Fill out this PROMS form, satisfaction survey, consent to share information…Data-fetishism creates an alienating rift between patient and practitioner.

We need to jettison the layers of bureaucracy that only gratify market-oriented administration. Money is tight, patients are waiting, and we need to deploy resources smartly. It’s our ethical duty.

Sean Roche is a consultant psychiatrist in North London, and was a visiting research fellow in philosophy at King’s College London 2012-14. After completing his philosophy PhD in 2011 he has maintained a research interest in philosophical and political issues that are relevant to both psychiatry and medicine.