German healthcare: quantity over quality?

Photo by Marcelo Leal on Unsplash

Dear Reader,

Apologies for not sending out either of the regular newsletters last week. I came down with a throat infection which ended up becoming so severe that I had to be treated in hospital.

I won’t scare you away with all the gory details. Suffice to say, my ability to swallow had become so restricted that I required emergency surgery in the back of my mouth.

I was released from hospital on Sunday and am now supposed to be recovering at home.

This seems like as appropriate a moment as any to write a newsletter on the state of the German health service.

Touch wood, but in over a decade in Germany this was only the third time that I had a personal reason to see behind the walls of a hospital. And, given that the other two occasions were the births of my children, it was the first time that I wasn’t glad to be there.

Admittedly coming from Britain, with our hopeless NHS, I’m easily impressed. But on each of my stays in a German Krankenhaus it felt more like being in a hotel than a hospital.

During the births of our two sons, my partner and I were given an en-suite private room as soon as we arrived, which was then ours until the birth was over. There was no waiting around in corridors until a few minutes before things got serious - just a bed to (try to) relax on and herbal tea whenever we needed it.

This time around, with a throat like a bullfrog, I was passed from my GP to an ENT specialist, who then sent me to the local hospital, which was a 15-minute walk from my home.

As soon as I had registered, I was hooked up to a drip and was operated on within an hour before being sent over to a ward for two days’ of recovery.

On the ward, I shared a room with one other patient, where we had a large flat-screen TV to help us pass the time.

All of that came on standard statutory insurance.

My experience seems to mesh with the big stats on the German health system.

Costing half a trillion euros a year to finance, it is the most lavishly funded in the EU both in absolute terms and as a percentage of GDP. Worldwide, only Americans spend more than the 13 percent of GDP that Germany imparts on its health system.

Germans pay an average of 8.5% of their monthly payslip towards healthcare coverage, with their employer contributing the same amount. And costs are set to go up again next year.

What does all that money get you? Plenty of hospitals, doctors and an abundance of beds. Waiting lists basically don’t exist in Germany: with 4.5 doctors and 12 nurses per 100,000 inhabitants, the ratio of medical staff to population is far higher than the European average. If you need surgery, there will always be staff there to ensure that you receive it promptly.

If you need a bed there is also guaranteed to be one waiting for you. With 8 hospital beds per 100,000 inhabitants, Germany has the second highest number in Europe behind only Bulgaria.

Most of the time, only around two thirds of these beds are actually needed. But once in a century a pandemic comes along and then the country can cheer the fact that it lavishes such vast sums of money on its hospital wards.

Thanks to this large reserve of beds, Germany was one of the few countries that was never seriously threatened with having to perform triage during the Covid pandemic.

But here is the strange thing about this system: rather than making people more healthy, it seems to make them more sick… or at least think they are more sick.

Just as city planners have long recognised that if you build roads you will reap cars, it would appear that building so many hospitals means that you reap illness.

Germans go to the doctor an average of ten times a year, more than most of their European neighbours. They are also around 30 percent more likely to end up in hospital than the French or the Swiss - while they also lead the charts for hip and knee operations.

Now, you could just see these numbers as proof that the German health system is brilliantly easy to access, meaning that people aren’t put off from going to the doctor by long waiting times or fear about the quality of the surgery.

But, if that were the case, you would expect to see better outcomes in the German system. In fact, the French and the Swiss systems seem to do a better job of treating patients, leading one to the conclusion that Germany may indeed be a country of hypochondriacs.

In terms of outcomes, Germany actually has the lowest life expectancy in the whole of western Europe. While life expectancy in France and Switzerland is pushing on to 84, Germans born today can only expect to live until the age of 81. Only east European nations like Hungary and Romania - countries with much higher rates of poverty - have citizens who will live shorter lives.

Meanwhile, a comparative study commissioned by the Health Ministry earlier this year concluded that Germany has some of the highest rates of preventable deaths in western Europe.

The study compared eight countries including France, Switzerland, the Netherlands and the UK and found that only Britain’s NHS system was worse at preventing deaths through treatment.

The authors found that better medical treatment could have prevented 81 deaths per 100,000 Germans in 2020. Best-in-class Switzerland had only 49 such deaths per 100,000 citizens, while France, Sweden and the Netherlands all scored considerably better.

Health System Performance Assessment – HSPA by the Technical University of Berlin.

What is causing such poor results for a system that is so generously funded?

One factor most experts cite is the way doctors are incentivised to carry out low-risk surgery. In the current set up, hospitals are paid per operation or action they perform, something called the Fallpauschale, or case flat rate.

This system increases the financial incentive to conduct an x-ray or a hip replacement operation but makes it less lucrative to carry out the more time-intensive work involved with nursing a stroke patient back to health.

A recent article in the Süddeutsche Zeitung summed up this state of affairs rather vividly:

“The Fallpauschale encourages doctors to give patients as many diagnoses as possible. It is a bit like a building in which carpenters, plumbers and electricians are allowed to install whatever they want. You end up with 37 cupboards, 18 bathtubs and 92 light switches - which means that the house will collapse.

In Germany, doctors carry out unnecessary X-rays, MRIs and laboratory tests that are not only harmful, but also make patients feel insecure because they think they are ill and in need of a check-up. In no other country in the world are so many back x-rays taken, so many coronary angiographies performed, and so many artificial joints fitted. But people here are not more sickly than elsewhere, they are just made sicker and treated with unnecessary medicine.”

This tendency to overtreat patients perhaps goes some way to explaining another oddity of the German system. Despite the country having far more doctors per head of population than countries like Switzerland and France, medical associations are constantly warning about the fact that there are too few doctors.

This was graphically illustrated this month when the fall of Syrian dictator, Bashar Assad, led to fears that Syrian doctors might all pack their bags and head back home.

There are some 6,000 Syrian doctors currently working in the German health system (5,000 of them in hospitals), making the Middle Eastern country by some distance the most important foreign source of medics for the German health system.

“Germany needs skilled medics from abroad to ensure that important healthcare infrastructure keeps functioning. Syrian doctors make an important contribution to our healthcare and their departure would certainly have noticeable consequences for the system as a whole,” warned the German Association of Medical Specialists in a statement last week.

At the same time though, there is a growing recognition that quantity alone isn’t necessarily the marker of a well-functioning healthcare system.

In one of its last acts before collapsing in November, Olaf Scholz’ coalition brought in a hospital reform that has set as its target the culling of several hundred hospitals as it attempts to put quality over quantity.

Advocating for the reform in the Bundestag, health minister Karl Lauterbach described the German health system as one in which you can get almost any surgery at almost any hospital, but also one that medical professionals themselves don't trust.

“In the vicinity of the University Hospital in Cologne there are 85 other hospitals that treat colon cancer, but they deal with hardly any cases and aren’t specialised - no doctor would ever go to them for treatment," Lauterbach said. "We owe it to people to offer them treatment that is so good that a doctor would also undergo that treatment."

In the future, only a limited number of hospitals will be allowed to offer specialised treatments like for colon cancer - but those that do survive will be highly specialised in specific types of surgery.

Secondly, Lauterbach said that he was doing away with the Fallpauschale system and replacing it with a system that rewards hospitals for having the capacity to carry out certain types of surgery.

According to the health minister, financial incentives mean it is easier to get a new knee than it is to get an appointment with a physiotherapist. “It is unethical that people with knee complaints are seen as the cash cows of the health system… this reform will stop the chaotic growth of operations based on financial incentive and return us to a system based on needs,” he claimed.

According to the government, several hundred hospitals will close down due to the reform with most of those that disappear being in west German cities. What this all means concretely is that there will be fewer beds, fewer wards and perhaps even fewer doctors and nurses. Quality rather than quantity, or at least that is how Lauterbach is trying to sell it.

The ENT unit at my local hospital, at any rate, is likely to be spared the exigencies of this efficiency drive. My roommate, who had just had his sinuses cleared out and looked like he had been hit by a bus, had come all the way in from the countryside of Brandenburg for his operation. The unit is apparently so well known that patients even travel from abroad to come under the knife of its doctors.

I certainly can't complain about the quality of the service. That's good news for me given the rate at which my children bring throat infections back from kindergarten.

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