20 April 2007
Doctors and insurance firms in Germany are up in arms over the 'NHS-lite' health reforms introduced on April 1. Greg Bousfield looks at the problems with the existing system and explains why ministers are looking to Britain for inspiration
Germany is a nation known for its feats of engineering design. Vorsprung durch Technik used to be the proud boast.
But in recent years this fabled technical expertise has started to let it down and the German health care system is no longer the well-oiled, well-designed machine of yesteryear. In fact, some say the wheels are in danger of coming off.
So much so that German Chancellor Angela Merkel has made health care reform one of her core public policy priorities. She has been drawing her inspiration from our very own NHS and from its centralised system of funding in particular.
But her government, an uneasy grand coalition between her Christian Democratic Union party and the Social Democratic Party of Germany, has provoked widespread fury as a result.
Since the controversial 'NHS-lite' reforms were forced on to the statute book by federal health minister Ulla Schmidt on April 1, the medical establishment has been queuing up to denounce them, and health professionals have been marching in the streets in their thousands.
When Schmidt launched the proposals last summer she bravely declared: 'This is the first health reform that isn't just a cost-cutting exercise but one that actually aims to solve the system's structural problems.'
But few are convinced. The opposition is being led by an alternative grand coalition of medical professionals, hospital representatives, pharmacists and the country's 252 public health insurance companies, or sickness funds. Their great fear is that the move towards an NHS-style funding system will bring with it NHS-style horror stories of patients lying on trolleys in corridors, months-long waiting lists and essential treatments being denied on cost grounds.
A protest statement recently issued by a group of doctors in Hamburg graphically sums up the protesters' mood. 'Unlike in Germany, NHS patients have to go to a GP before they can see a specialist. Then they have to wait sometimes more than six months for an appointment with a specialist, which means patients also have to insure privately. If the specialist recommends an operation, patients often go back to the NHS for this – but have to wait again,' it warns.
'This is the sort of system that Ulla Schmidt wants to introduce. We call on Chancellor Merkel to prevent this, so we don't succumb to British standards.'
The reason for the German government's doggedness in the teeth of such opposition is its belief that the current system of funding cannot be sustained. Last year, the health system cost €145bn and had a funding shortfall of €7bn. Under the system, employers and employees pay compulsory contributions into one of the 252 sickness funds, which insure around 73 million people, or 90% of the population. The funds set members' contribution rates – which currently average 14.2% of gross pay, split between employers and employees – and determine the health care services provided to members.
But rising costs, low birth rates and stubbornly high unemployment mean these contributions have failed to keep pace with the costs of the German health care system.
To tackle these structural problems, the government has come up with a modified version of the regime – itself a compromise solution reflecting the political tensions within the ruling coalition – to make it more affordable.
The centrepiece will be a new federal government-administered health fund, which will collect all the contributions currently going into the sickness funds. Rates will be frozen at 15.9% in 2009 and the money will go directly into the new central pot. The government will top this up, initially with €2.5bn this year and next, and then with an annual €1.5bn injection.
It will then distribute this money to the funds, based on numbers of members and controversial individual patient morbidity risk profiling, the criteria for which have not yet been finalised.
Funds that lose out will be allowed to levy an additional 1% contribution on individual members (not employers) to make up the shortfall.
Unsurprisingly, the sickness funds are not wild about the new system. They are incensed at the threat to their autonomy and have been campaigning hard against the changes. 'These reforms will create a central bureaucracy and threaten sickness fund jobs,' says Rolf Hoberg, chief of Baden-Wuertenburg AOK, the country's biggest cross-regional sickness fund. 'They don't stabilise the financing of the system. We need a proper debate about more financing of the health system out of tax.'
Warnings that the reforms will threaten health standards are being taken seriously by health professionals, who have staged a number of strikes and days of action over the issue.
Jorg-Dietrich Hoppe, president of the Federal Medical Association, warns that the changes will lead to fewer hospitals and lower standards of care. 'When more than 40 organisations from the health occupations form an alliance to protest, then something must not be right. The reforms do not provide a sustainable funding base for the health system,' he says.
Independent experts seem to agree. Thomas Esenberg, head of the health section at Germany's national Consumer Centre, says the new regime will not achieve its main aim, and the government should have been more radical if it were serious about improving the financial picture. 'There is no big improvement in terms of maintaining the long-term affordability of the system in the reforms,' he says. 'Levying contributions on all income, for example, and not just on wages was not even considered.'
Ironically for the government, it is the public's suspicions that the reforms are all about hiking up costs and raising more money that has made it deeply unpopular.
In particular, Germans are concerned that they will have to keep pouring money into a system that costs a quarter more than the NHS but somehow still leaves them with a slightly lower life expectancy than in the UK. Polling conducted before the reforms came into effect found that 70% thought the reforms were ideologically driven and there had not been proper consideration of their practical impact.
Seventy-five per cent thought that it would damage health care delivery, and 65% thought the reforms would have a negative effect on them personally.
Angelika Burkhard, a 50-year-old office worker in Berlin, is typical. She says there has been a noticeable shift towards charging for services that were previously free. 'In the past few years you have had to pay upfront for more things, like having your teeth cleaned at the dentist or for basic eyeglasses, whereas before you used to pay only if you wanted expensive frames.'
Burkhard says she expects that trend to accelerate under the reformed system and is not persuaded that services will improve. 'The government originally said that there would be no contribution rate increases. But I think most people believe that the reforms will just cost more.'
There are other strands to the health reforms: some less controversial than others. For example, there is no disputing the fact that rising prices for the record 30,000 drugs that Germany has on the market have severely affected the affordability of the health system.
The reforms are introducing cost-benefit requirements for drug market approval, like in the UK, and doctors will have to get a second opinion before prescribing expensive drugs. The government is also making some attempt to introduce a GP-gatekeeping system, to discourage people from going directly to expensive specialists. And more preventative screening will be introduced at the primary care level.
But with Germany's doctors and health federations threatening more industrial action, and with widespread public suspicion, the health reforms are far from home and dry. Ironically, just as the British government is encouraging less centralised control over its health trusts, the German system seems inexorably to be moving the other way.
PFapr2007
