Berlin The Minister of Health was able to see what the hospital landscape of the future would look like Karl Lauterbach (SPD) recently experienced for themselves. At Hadassah Hospital in Jerusalem, he donned a blue robe and roamed the corridors of the fourth-level intensive care unit.
There are 13 operating rooms for 27,000 operations per year, all equipped with the latest technology – for example a robot for surgical interventions that can be operated remotely. “We are here in Israel to learn,” Lauterbach said.
With a hospital reform, the Federal Minister of Health wants to reorganize the German hospital landscape. It’s a mammoth task. The last major reform was 20 years ago. The system with around 1,900 clinics and their more than 400,000 employees is considered expensive, ailing and inefficient.
In addition to these structural problems, clinics are struggling with external shocks such as the corona and now the energy crisis. According to the hospital rating report by the Leibniz Institute for Economic Research RWI and the Institute for Healthcare Business, 60 percent of the facilities are there deep in the red, 20 percent are even at risk of insolvency.
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Lauterbach’s reform is therefore becoming a major maneuver. Think of it like open-heart surgery. It is about the question of how to reform a system while it is in operation. In addition, there is a network of powerful interest groups that all want to have a say. Lauterbach has to reckon with fierce resistance.
This became clear on Tuesday, when Lauterbach received the first results of the hospital commission, which is working on reform proposals for the minister. “We operate far too many beds and have far too many inpatient admissions,” said Lauterbach, back in Berlin, in the atrium of his ministry during a press conference.
The proposal that the Lauterbach Hospital Commission therefore made sounds unspectacular at first glance. Unnecessary overnight stays during clinical examinations should therefore be eliminated in the future. There will be a new legal regulation for this, announced Lauterbach.
For example, cancer patients often come to the clinic for four or five days for special examinations and treatments. “But actually you don’t have to stay in the hospital at night during this time,” said the minister. Treatments with actually unnecessary overnight stays are not uncommon, but have been a central problem for a long time. The reform will help quickly and will not cause any additional costs, but may even save money.
The criticism from the healthcare industry was not long in coming. You feel left out there anyway, since the interest groups are not part of the hospital commission. So you can always only get rid of criticism when the proposal is already in the world.
A “big hit looks different”, etched the head of the National Association of Statutory Health Insurance Physicians (KBV), Andreas Gassen, on Wednesday. The chairwoman of the AOK federal association, Carola Reimann, said that the project threatened “new, additional expenditure in the billions, without the contributors getting any added value”.
The head of the German Hospital Society, Gerald Gass, however, said that the proposals for more outpatient treatments were going in the right direction and could relieve the staff. “The problem is that the government commission works without the involvement of practitioners.” That urgently needs to change.
Lauterbach does not want to be impressed by this. His house is “very resilient in terms of lobbying pressure,” he said when presenting the proposals. It goes “always on”. He has chosen an interesting strategy for this, namely a reform of the mini-steps.
Hospital reform in mini steps
So did his predecessor Jens Spahn (CDU) with digitization. Instead of writing a big law that takes a long time, Spahn wrote one law after the other in order to get individual digitization projects such as the electronic prescription, the electronic patient file and the app on prescription off the ground.
“Nowhere are the failures of the past 30 years in the healthcare system so evident as in the hospital landscape.” Jochen Werner, head of the Essen University Hospital
Lauterbach also takes these mini-steps to patch up the system at different points. An energy package worth billions should help the clinics to cope with the higher electricity and gas prices. Children’s clinics, of which there are fewer and fewer, are to be removed from the system of flat rate per case in order to be better financed.
And a new tool for personnel assessment should mean that clinics will have to employ as many nursing staff in the future as are actually needed. Hospitals that do not meet the requirements must expect sanctions from 2025.
Lauterbach stirs up a lot that is heard very carefully in the clinics. “Nowhere else are the failings of the past 30 years in the healthcare system as evident as in the hospital landscape,” says Jochen Werner, head of Essen University Hospital, to the Handelsblatt. “It’s annoying.”
Behind the university hospitals in North Rhine-Westphalia is a month-long strike that has now been settled with a new collective agreement. For the University Hospital Essen, it means that 300 new nurses have to be hired. It is currently 2000.
“It’s not easy,” says Werner. The new collective agreement does anticipate the new personnel assessment planned by Lauterbach. He may have to poach nursing staff from other facilities. “So that will tear holes elsewhere, up to and including the already poorly staffed care for the elderly,” he says. “Bottlenecks will only be relocated if we don’t finally change structures.”
Werner recently published a book entitled “Our Hospital is So Sick”, in which he dissects the structural problems in detail. For example, it has been known for decades that there are too many clinics. The consequence is the lack of care, and hospitals also pollute the environment considerably.
“That’s why it’s important to close the too many hospitals,” he says. One in three hospitals could close to meet demand with existing sites, according to a 2020 study.
However, the topic is sensitive because the closure of entire locations is difficult to convey to the population. The federal states are also responsible for this. North Rhine-Westphalia recently presented a concept, while others let the topic slide completely. But there is no federal plan. It takes courage to “really change something,” says Werner.
The man who has to muster that courage is Tom Bschor. He heads the Lauterbach hospital commission and is a specialist in psychiatry and psychotherapy. The commission has already met 30 times since mid-May, mostly via video, which is a considerable amount of work for such a body.
The hope is that a plan will also emerge as to where which clinics are located Germany are needed – and where not. Anyone who still remembers the reactions to Lauterbach’s most recent reform proposals can imagine what would happen in the country if clinics were to close.
Closing clinics – a difficult mission
However, the task is not to determine how many clinics have to be closed, says Bschor. “Our goal is to say how much capacity is needed in the individual disciplines.” The discussion is about using certain reference values such as demographics or social structure.
In paediatrics, for example, it is not the total population that matters, but the number of children. A cardiology or a stroke unit for stroke patients is more relevant for the older population. Trauma surgery, on the other hand, is more likely to be needed by younger people.
The situation is currently that in some rural regions the offer is declining, while in other places one clinic is lined up after the other. In addition, there are huge false incentives. Small clinics, for example, offer treatments in order to generate income without coming up with the relevant case numbers and quality.
This is a problem because patients die less often in clinics with high case numbers. In the case of a heart attack, it is 31 percent less, and in the case of pancreatic cancer, it is even 54 percent. On average, more than every second cancer patient in Germany is currently not treated in specialized centers.
In the coalition agreement, the governing parties therefore agreed, among other things, to base hospital planning on clear criteria such as actual needs and accessibility. In rural areas, smaller clinics would receive flat rates for basic needs, while complex interventions would be carried out in centers.
Bschor must implement these wishes. Bschor obviously has the foreseeable resistance, for example from the countries, in mind.
“One conceivable variant is that the commission or the federal government recommends these parameters to the states and they then have to decide which hospitals or departments need to be enlarged, reduced or possibly closed completely,” says Bschor. “Financial incentives are also conceivable.”
He now sees an opportunity for “fundamental reforms”. Not much can be gained with “a few reforms”.