Escaping the tentacles of the bureaucratic squid


Philosopher René Ten Bos likens the current regulatory burden in the public sector to a bureaucratic squid (2015). It’s difficult to get a grip on such an all-encompassing and slippery phenomenon. Before you know it, you’re caught in the squid’s grasping tentacles.

Recent efforts to get rid of red tape in healthcare are brave attempts to tame the bureaucratic squid. But is that enough? Research by Erasmus School of Health Policy & Management into the regulatory burden (Van de Bovenkamp et al. 2017) suggests not. It’s not so much a case of getting rid of all rules, but about fundamentally rethinking accountability and creating the right type of regulations that enable reflection about good care. The good news is that a number of healthcare organisations are already experimenting with this approach. What can we learn from them?

From regulatory reflex to reflexive mirroring

Person-centred care is only possible when regulations are not taken for granted, but are questioned and adapted to the personal situation of each client/patient. Healthcare workers do not necessarily want to work without any regulations,  rather they are looking for appropriate regulations that enable them to reflect on what constitutes a good standard of care. This might involve mirror interviews with clients and family members or working with the method ’Images of Quality’ (in Dutch: ‘Beelden van Kwaliteit’). According to this method, healthcare providers are trained to observe the normal daily routine in a department. Their observations are discussed with a panel of stakeholders from inside and outside the organisation (patients’ council, Supervisory Board, insurers, municipal councillors). Their reflections are then discussed with the observed team at a meeting that is also attended by the team leader. In this way, a reflexive dialogue is established about what actually constitutes good person-centred care, how it should be provided and the dilemmas it presents in the daily routine of work.

Encourage rebels

Embrace people who question the status quo and are able to create new micro-systems for good healthcare. These are people who push organisational boundaries without placing themselves outside the organisation: they rock the boat, while staying in it.

Involve different organizational levels in creating appropriate regulations

At the same time, it is simplistic to claim that headstrong individuals alone are enough. Since the reach of regulations often extends organizational boundaries, the discussion about appropriate regulations must be conducted with various organizational levels, people and organisations. Often, this is not the case however. We hear healthcare workers say, for instance, that regulations are ‘thought up by people in the office’ or ‘are imposed’ by bodies such as the Inspectorate. This illustrates the gap between policy and practice. Recoupling these various levels is crucial for tackling the problem of regulatory burden. The red button that some organisations have introduced is a helpful tool. When a healthcare worker comes across an absurd or cumbersome rule, they can press the button. A manager will meet up with the healthcare workersto discuss a solution.

Make accountability more narrative and generative

Whilst it is important to record some quantative targets, they are not enough for a proper discussion about quality. It is therefore important to enhance the narrative (story-telling) and generative (learning-driven) aspects of accountability. Initiatives like ‘Beelden van Kwaliteit’ and the new approach for writing quality reports in the care sector for people with disabilities , are great examples.

It’s clear that some healthcare organisations already have taken significant steps towards new, experimental steering models. They have started (tentatively) taming the bureaucratic squid. Which care organisations will follow their lead?


This blog was written by dr. Lieke Oldenhof and dr. Annemiek Stoopendaal.

More information


  • H.M. van de Bovenkamp, A.M.V. Stoopendaal, M.E. van Bochove, H. Hoogendijk & R.A. Bal (2018). Persoonsgerichte zorg, regeldruk en regelruimte: van regelreflex naar spiegelreflex. Rotterdam: ESHPM
  • R. ten Bos (2015). Bureaucratie is een inktvis. Amsterdam: Boom Uitgevers.

Compare @count study programme

  • @title

    • Duration: @duration
Compare study programmes