To close a chapter on bureaucracies with a discussion of the healthcare industry might seem surprising. What can this highly specialized field which is about devotion and real concern for humankind have to do with the pencil-pushing routines of technical organizations forging ahead with their own way of thinking without concern for customers?
The link is this: in nearly every nation people are involved in a heated debate over the problem of rising health costs.21 Yet very few people realize that there is an organizational dimension that must be addressed.22 Hospitals – which generate the majority of costs in question – can in fact be viewed as the most perfect form of what we have called a technical organization. Because of a need for specialization, which “customers”
are all the more ready to submissively accept since their own health is at stake, a hospital does not really deal in terms of sick people, but in terms of illnesses and body parts, so to speak, and this way of function- ing has become quite naturally the hospital’s guiding principle. Edgar Morin and Sami Naïr write:
High tech medicine, while producing wonderful results (liver, kidney and heart transplants, the restoration of injuries or war wounds, the reversal of many infectious diseases), suffers from and makes patients suffer from hyper-specialization, according to which the body’s organs are viewed as separate from the body, and the body separate from the overall being, be it biological, psychological, or social.23 This hyper-specialization does not just pose a human problem, that of
“dissected” patients, as if they were automobiles on the assembly line or in for repair. Hyper-specialization poses the problem of cost for reasons which we have already seen in this chapter. The technical rationale, pushed here to the extreme, allows doctors to avoid cooperating, even getting the patient to help them in avoiding it. The anxiety-provoking nature of the doctor–patient relationship leads the latter to accept and even approve of repetitious exams or treatments. In public debate, whenever people begin to criticize the high cost of these treatments and seek to control them through a purely financial approach – such as for- cing doctors to cut down on treatments and prescriptions – practitioners cry wolf and warn of the imminent degradation of public health. Those who are currently sick or potentially sick are quick to join in this out- cry. In the end, there is more and more disagreement over solutions, if What is a Bureaucracy? 57
only because no one has really understood the problem, and there are precious few who actually see the link between the care which they receive and the deficits of a system as abstract as Medicare in the United States or social security in Europe.24
Thus healthcare is really no different from the other organizations we have already seen. Cost and quality are not really at odds, but so long as they are viewed as such there will indeed be a decline in benefits in a game in which the stakes are high and everyone loses: as a whole we will only partially be able to control costs, patients will receive care of lower quality, and doctors will experience a drop in their standard of living. The latter, just like everyone else we have encountered, are going to have to learn to work differently, in a less segmented fashion, thus less comfortably. They are no doubt going to have to get used to a little less prestige in their particular area of specialization. At the same time, their relationship with patients is going to have to change just as radically as the relationship with the customer in any kind of bureau- cracy: this is, no doubt, where the stakes are highest. This will affect what people actually do at work (their “occupations”) on a daily basis.
Readers who find this argument difficult to accept should reflect back to the days, now past, when doctors, by being systematically late, made patients feel all that much more dependent on them. To rebuild the hospital around the patient is not a dream. Not only can it be done, but it should be done, for it would result in improved care at a lower cost. Why would we not treat this particular sector the same as all others, regardless of how difficult it might be for the producers, in this case the doctors?25Certain countries have already taken the first steps in this process, either for budgetary reasons as in the United States, or because they are involved in national reconstruction, as in Lebanon, and thus have a chance to rethink the functioning and structure of their healthcare system.
There is no question that once again we are dealing with a real revo- lution. For, in countries such as France or Belgium, not only is there the medical bureaucracy, but there is now a bureaucracy that manages healthcare. In Paris, for instance, women are taken to special hospitals for the birth of extremely premature babies; the premature babies are cared for in entirely separate hospitals. Premature infant delivery and premature infant care are two different “practices”, so to speak, so that in the Institute of Infant Care in Paris, there is not a single maternity bed. The segmentation of healthcare is thus based on the rationale of the hospital’s organizational chart; but as it respects the various special- ists, it increases both cost and risk.
More generally, what is being challenged here is the way bureaucrats and politicians go about trying to reduce public expenditures. We had a good example of this way with the case of public transportation. An exclusively financial approach which favours actual “gross” gains in productivity by simply reducing identifiable costs can only wind up hurting the overall quality of services provided, or might force them to be eliminated altogether. The artificial view that cost and quality are irreconcilable, which stems from a complete misunderstanding of the organizational dimension of the problem, leads many to take a hopeless view of reducing public expenditures, and results in disagreement after disagreement in the debate over how best to go about it.26
The lack of real debate on these issues, but also the particularly violent reactions which they cause in France, Belgium and Italy, are clear signs that citizens are aware, however vaguely, of the erroneous path on to which they have been lured. In fact, wiser than their own leaders, they cannot understand why the public sector is the only one not to offer improved services at lower cost. From this standpoint, they have entered into the same struggle with government as the customer with the producer. What they want is reform of the state and of the way it operates. Their leaders have yet to make it part of their agenda.
Generally speaking, they do not understand what such reform would mean in terms of the organization of public or para-public services.
Thus they make do with traditional approaches to the budget which resolve nothing and displease everyone, and sadly miss a wonderful opportunity to give real meaning to an initiative that would change the way the state and its agencies function. That is unfortunate, since we will all pay for it later on.
What is a Bureaucracy? 59
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4
A Requiem for Bureaucracy
We enjoy bureaucracies. Those in which we work, that is, not those which we have to confront and which bind us with constraints. We are, in fact, both the bureaucrat and the customer: we apply pressure and we resist it, we demand change and yet we cherish the advantages that are already ours. There is no real contradiction here, as a number of writers have already pointed out.1 Our ability to play both roles is to a large extent the result of how difficult it is to identify, or “flesh out” bureau- cracy, so to speak, when it is defined in terms of the line of thought gov- erning the implementation of its modes of functioning, and in terms of the employee benefits associated with them. So long as this definition remains relatively abstract and general – the ability to produce general and impersonal rules and to apply them, for example – so long as it underscores the trivial, day-to-day aspects of bureaucracy, just as Balzac2 described the bureaucrat – paperwork, drawn-out procedures, little con- tact with others – bureaucracy resembles any large organization, a mili- tary model3 or a form of public administration. And so bureaucracy is referred to as “them”, even for bureaucrats themselves, who are all the more ready to point out the ungainliness of the world they work in, since doing so allows them to point out their own flexibility.4
This is misleading, and it allows businesses in the private sector to preserve a good image by distancing themselves from the public sector. In fact, this distance is not as great as they would like us to think. In order to prove this, I will begin by showing, through several simple examples, that there are as many small bureaucracies as there are large ones, that bureau- cracy is not defined by size, that the basic problem is how an organization is conceptualized. From this standpoint, knowing that the elite of the pri- vate and public sectors overlap both in the United States and Europe, the modes of thinking are both here and there more or less the same.5