more_vert
Many vulnerable people are excluded from the support they need by administrative red tape that leaves them overwhelmed and disempowered, writes Dr Louise Stone.
As a general practitioner, I recently saw a young man who was sleeping rough. He’s had a tough life. Like 50% of the people in this country who left school around year 10, he doesn’t have the literacy to manage everyday life. I asked him if he was receiving payments from Centrelink. “Nah”, he said, “I tried to get Centrelink, but when I went in there, they told me to use the computer. I can’t, so I left”. He went back a few years later with his dad, but “they gave me this form and it was 24 pages. We chucked it out”. I asked him how they manage to cope without support. “We beg”, he said wryly.
What is administrative harm?
As a general practitioner, I see administrative harm all the time. The National Disability Insurance Scheme (NDIS), My Aged Care, Centrelink, Veteran’s Affairs, Workcover and other systems are optimised for those who can read in English, have access to digital devices, have at least some control over their own paperwork and have the confidence to be very, very persistent. Unsurprisingly, the poorest, sickest, most marginalised, and least white tend to miss out.
You need trust to access care. Entering your sensitive data into a faceless database requires a degree of faith in administrative systems and government which may well be misplaced. If you were a victim of Robodebt, or your data have been compromised in one of the many hacking incidents in recent years, or you come from a country with a corrupt administration, you are unlikely to have such faith. My patients who live with domestic violence are also understandably reluctant to use systems that may identify them to others.
There are an army of good people and organisations around Australia trying to help people manage administrative harms. Advocates, volunteer financial advisors, youth workers, non-government organisations, and many, many others work with Australia’s most vulnerable people to ensure they get the support they need. But it’s not enough.
The cost of red tape to providers, consumers and carers
Recently, I helped a woman with early dementia get through the paperwork she needed when she had to leave her job. She’s one of the lucky ones, with two intelligent and capable kids. By the time we secured her a disability support pension, NDIS, and the specialist diagnosis she needed to access both, I had spent five hours with her and her family. Just on administrative needs.
I even had to spend 20 minutes finding a nurse practitioner to sign off so she could get a subsidy for her diabetes equipment. In a staggering misunderstanding of my clinical skills and 14 years of training, the government has decided I don’t know enough to fill in a subsidy form for the National Diabetes Services Scheme (NDSS). A nurse practitioner can, so I had to waste 20 minutes finding one willing to sign. When we questioned a representative of the NDSS as to why general practitioners shouldn’t fill out a subsidy form, he replied “because insulin is a dangerous drug”. I’m sure the nurse practitioner knows this, but so do I.
Families waste much more time. They learn endless acronyms, search through layers of online documents, and have to find appropriate evidence to justify each question on the mountains of forms they are required to complete. Often the patients feel useless, guilty, overwhelmed, and, despite our best efforts to include them in every decision, deeply disempowered.
When I started in general practice, we did all this with a district nurse and, where necessary, a social worker. It was more humane, and I suspect it was significantly cheaper for the taxpayer.
Duct tape jobs
In 2013, anthropologist David Graeber published an article that highlighted the harms associated with pointless work. He called for a cultural shift, valuing creative and caring work over empty tasks, and introduced one form of pointless labour he calls “duct taping”.
Duct tapers fix problems that should not exist. If the system were better organised, then it would not need to taped together to make it work. Duct tape jobs in general practice include rewriting referrals because hospitals have complex and opaque referral systems that general practitioners cannot navigate, responding to endless requests for information that has already been provided to multiple organisations, consulting with carers and consumers to help them navigate increasingly complex pathways, and addressing therapeutic “dead ends”, when patients are repeatedly referred and rejected.
General practitioners are asked to supply increasing volumes of paperwork to enable patients to get the care they need. Frequently, the paperwork needs to be supplemented by phone calls, emails and other methods of advocacy to ensure the patient is accepted into the care they obviously deserve. Sometimes, we need to “sell” patients, calling in personal favours, professional connections, and attractive narratives to persuade others to care for our patients. This form of begging is demoralising and should be unnecessary.
Duct taping from general practitioners is the reason many patients don’t “fall through the cracks” of the health care system. However, duct taping is expensive for general practitioners, who are rarely paid for this form of labour. It also causes moral injury, because highly trained and intelligent health professionals deeply resent the pointlessness of the tasks involved.
The role of tape in workforce attrition
Red tape and duct tape strangle general practitioners, not only using up time, but also using up emotional resources. It is, frankly, soul-destroying to waste time on paperwork that doesn’t need to exist.
In the past few years, the federal government has conducted multiple general practice audits that consume time and energy. The behavioural economists say this is to reduce “low value care”. Perhaps it is time we applied the same lens to administrative harms and started reducing “low value red tape”.
We general practitioners currently spend an extraordinary amount of time on unpaid paperwork or other administrative tasks. Most of it seems pointless. If we spent even half that time seeing patients, we could have 16 million more appointments available to patients per year. I doubt governments are saving that much time and money through all the administrative processes they impose, given how much these processes cost. During Robodebt, I remember the epidemic of mental illness caused by that particular administrative harm. I’m sure the money saved didn’t begin to compensate for the cost to the people targeted and to the health care system who tried to care for them.
It is time governments were held accountable for the administrative harm they cause. No-one should have to beg because they can’t read a form.
Dr Louise Stone is a Canberra GP with clinical, research, teaching and policy expertise in mental health. She is an associate professor in the Social Foundations of Medicine group, Australian National University Medical School.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
Subscribe to the free InSight+ weekly newsletter here. It is available to all readers, not just registered medical practitioners.
If you would like to submit an article for consideration, send a Word version to mjainsight-editor@ampco.com.au.