On the problem with German hospitals

German hospitals have enough beds... staffing is the problem.

Given that the following information demonstrates serious failure on the part of the German government, it is surprising that it isn’t more widely known.

Back at the start of the pandemic, the Health Ministry realized that it needed to buttress Germany’s intensive care capacity in order to avoid scenes like those in Bergamo, Italy, where hospitals couldn’t cope with a deluge of patients.

So Health Minister Jens Spahn created the COVID-19-Krankenhausentlastungsgesetz (Covid-19 hospital alleviation law), which was intended to increase Germany’s intensive care capacity by offering hospitals financial incentives.

Specifically, the law pledged a one-off €50,000 payment for every extra bed that they could create that could be used for intensive care treatment. To be eligible for the money, hospitals had to either repurpose beds or create new ones equipped with respirators.

Things moved quickly. In early August 2020, the national intensive care register added a further 12,000 ‘emergency reserve’ beds to its record. Germany thus had 40,000 intensive care beds to call on - a capacity most other countries could only dream of.

Slowly though, this number turned out to be something of an illusion.

In the autumn of last year, the Association of Intensive Care Wards (DIVI), which runs the national register, appealed to hospitals to only count beds that they actually had enough staff to man. Within a few weeks the total capacity had dropped down to under 35,000.

By the summer of this year, that number had fallen further to 32,400.

Then, in June 2021, the government published the numbers on how many times it had paid out the €50,000 bonus: hospitals had claimed the money for a total of 13,700 extra beds - an increase in capacity that had been subsidized with €686 million in federal cash.

There was an obvious contradiction here: hospitals were applying for state funds based on new ICU beds while the number of beds recorded on the national register was falling.

The immediate suspicion was that some hospitals had been committing fraud.

“Have the hospitals been billing for beds they don’t have?” asked broadcaster ARD in an investigative piece on the subject.

“If it turns out that hospitals applied for funds in the peak phase of a pandemic without also creating the required beds, that would be an unparalleled scandal,” said Social Democrat MdB Hilde Mattheis.

The truth appears to be a bit more complex though. As the Ärzteblatt, Germany’s doctors’ newspaper, explains, hospitals most probably did create the extra beds. They followed the letter of the law by buying respirators and setting aside capacity. The law itself makes no mention of the fact that the beds also need to be staffed with nurses.

Whether hospitals did this in full knowledge that they didn’t have enough staff is unclear. Some made efforts to retrain nurses on other wards. But most clinics were already suffering severe staff shortages before the pandemic - they must have known that creating beds without increasing personnel was pointless.

That staff numbers actually kept falling throughout the pandemic is made clear by DIVI’s intensive care register, which only records beds that hospitals have the staff to take care of them. As can be seen in the chart below, the overall capacity has been dropping slowly since October of last year.

This stark loss of manpower was confirmed in a recent survey by the German Hospital Society (DKG), which found that nearly three-quarters of hospitals have fewer critical care nurses available today than they did at the end of 2020. The main reasons cited in the survey were layoffs, staff switching to other wards or reducing their working hours.

Nurses at some hospitals have been on strike in recent months, complaining of burn-out due to overwork and a poor level of pay.

A year ago, Spahn said he recognized the need to train up new staff to deal with the extra burden caused by Covid.

He told Deutschlandfunk in November 2020:

“Some people are now saying that there were shortages in March, so why aren’t there staff now in November? But intensive care is a training that you can’t acquire in three or six months. It takes much longer. That’s why, as I said, it’s a marathon.”

Spahn promised that measures such as a €1,000 bonus for new trainees would turn things around.

“There are a lot of big and small levers that we have already pulled - not only in word but also in deed - and I think we have to talk about these successes if we want people to choose this profession,” he said.

Well, he’s had another year to finish his marathon. At least some initial successes should now be evident. Instead, the number of staffed beds has never been lower and the staff that have stuck around are on strike over poor working conditions.

That is a pretty miserable record for the outgoing Health Minister, and one that means that a lockdown for the third winter in a row is becoming increasingly likely.