By Polly Toynbee
The Guardian, Wednesday 16 March 2011
What would Professor Ulrich Frei, medical director of Berlin’s mighty CharitĂ© university hospital most wish for? “No more healthcare reform! At least for three years, please. Sometimes we have one a year, with no time to plan. It follows the electoral cycle and so does health funding, and that makes rational planning impossible.”
Sound familiar?
There are plenty of lessons for the UK to learn from German healthcare, as seen from this towering red-brick turreted institution. Founded in the 18th century by Frederick William I, the Prussian monarch, CharitĂ© was bombed to dust in the war, rebuilt as a concrete East German monument, right up against the wall. On reunification, it was reconstructed again, to its former splendour. But it’s in debt.
Across Europe the politics of health is intense. Everywhere, the mammoth generation born just postwar is reaching retirement, demanding more hi-tech treatment and better social care while projected to live longer than any previous generation. Each country responds as if it were uniquely burdened, frequent fidgety reorganisations, with health one of the most certain triggers of political indignation.
Systems differ, built on each country’s distinct social history, all reflecting national stories. But all are basically state-funded through taxation, even if at first glance they look like insurance schemes. Essentially, the working healthy pay for the sick and the old, who are the heaviest users of care.
A commitment to universal, collective provision distinguishes Europeans and divides them most strikingly from the United States (but not Canada). It has been this “socialised medicine” commitment that the Tea Party faction has fought so ferociously in its rejection of the Obama health plan. In Germany, the state pays for 77% of healthcare, in the UK it is 83%, while in the US the government covers only half as much.
Germany spends 10.4% of GDP on health (public and private), considerably more than Britain, which on 2007 figures was just below the EU average at 8.4%. How far are these ratios based on cultural and historical assumptions? Germans say they feel sicker: they certainly visit doctors a lot more than the British, on average 12 to 14 times a year.
Soaring costs are seen as a political crisis in Germany: home care for the frail rose by 11% last year. As Britain raced to catch up during the Labour years, Germany spent only an extra 1.7% each year. One result has been to push health up the political agenda: patients are complaining that it takes longer to get treatment.
Walk the wards of CharitĂ© and you witness state-of-the-art treatment and research. This year’s excitement is a new MRI scanner that is open, no longer a confining tube. It recently filmed the first-ever MRI birth, showing that babies’ heads are much more tightly compressed during birth than anyone had realised.
Whatever the German debates, its healthcare has been better funded for far longer than the UK’s, and it shows. Germany scores better than the UK on cancer and stroke survival, although overall survival rates are much the same. The health of nations, however, is less about healthcare than the way we live. Germany has more car accidents, more smokers, and more teenage suicides. Britain and Germany eat and drink about the same amount – too much – while UK infant mortality is worse. German life expectancy is a little higher.
What Britain might learn from Germany is not to turn our relatively efficient healthcare system into a bureaucratic paperchase between the funders and the providers of care. Superficially, their system looks quite different. All citizens belong to one of 160 insurance mutuals; the choice of fund seems relatively insignificant. They bear the footprint of Bismarck, who devised a social support system in the later 19th century to counter the threat of socialism. People used to join a mutual linked with their industry or sector.
For everyone, the same 15% is deducted from wages, with employers contributing about half. The state pays for those who can’t afford it, and about one in 10, the better off, insure privately, paying for faster and more luxurious treatment. Two-tier care seems to stir up more political resentment in Germany than the similar proportion going private in the UK.
But the money the insurance funds pay out has been exceeding their income, and the federal government has been topping them up and insisting on increases in premiums; funds traditionally catering for manual workers have been running out of money first. Some funds tried adding small monthly surcharges only to see a mass exodus to other funds. But because insurance is compulsory and fees identical, what the Germans have is essentially a tax-based scheme. Reform is a hot political issue, not least because in a highly bureaucratic system, administrative costs are exorbitant and rose by 5.8% last year.
Professor Frei, pressing his fingertips together at his desk at the CharitĂ©, explains why – and the British “reformers” should attend. The process by which the insurance funds buy treatments is complex, generating wads of paperwork and many disputes that are resolved only by special medical tribunals. There is a perpetual tussle as the funds try to hold down costs and hospitals try to inflate them.
Only about a fifth of German doctors are in primary care, like GPs. In principle, all patients can look up a consultant in the yellow pages and refer themselves – although insurance will cover only one consultant for the same complaint every three months, for those who want second opinions. Ways to cap rising prescription costs, hospital bed use and doctor visits are politically controversial. Germany has a third more doctors and 8.2 hospital beds per 1,000 population compared with Britain’s more economical 3.4 beds. Insurance companies are starting to offer lower premiums to those who always agree to see a GP first.
Six years ago they moved to a US-style accounting system based on disease-related groups, which fixes a tariff for every treatment. An elderly patient entering hospital with a broken leg gets a set sum of money for the leg, but if she has complications later, no extra is paid. Hospitals play the system, trying to register patients as higher-tariff cases while insurance companies hire a fleet of their own doctors to challenge as many bills as they can.
Frei complains that a quarter of his doctors’ time is spent dealing with bureaucracy related to these payments. “If there is anything slightly technically wrong with the documentation, the insurance companies pounce on it as a reason not to pay. We lost €12m (ÂŁ10.4m) that way last year.”
Worse, the system is creating perverse incentives for doctors and hospitals to over-treat. “Knee replacements went up by 18% last year. It’s why invasive treatment for heart arrhythmia in the over-70s rose by 10%. Everyone has back pain, but we operate more every year because it pays more. Is there evidence back operations are the best treatment? No. But then we don’t have a National Institute for Health and Clinical Excellence [Nice] like you do, to give a rational assessment of the relative value of treatments. I wish we did.” He is alarmed to hear the Cameron government has weakened Nice and truncated its remit.
Pressure of rising costs and suspicion that patients are being denied treatments for reasons of cost has the health system caught in the political crosswires. The Social Democrats on the left want to rationalise the system into a free service for all, cutting the paper trail. The health minister comes from the free-market Free Democrats and advocates the opposite – total privatisation of all hospitals (two-thirds are state or non-profit) with a flat rate, non-means-tested insurance payment, freezing employer payments. A flat-rate would hit the poorest har
dest. Angela Merkel’s Christian Democrats want a bit more privatisation.
Frei says the fifth of hospitals that are privately owned are indeed more efficient, better managed, and make a profit even though officially they can’t compete on price, with the same tariff per case. But, he complains: “They cherry-pick the easy cases, and although it’s illegal they offer backhanders to doctors to refer cases to them. In private hospitals, heads of department have it written into their contracts that they must go to outpatient clinics once a week to meet doctors in the community to drum up business and solicit referrals. That leaves us to do all the expensive tertiary cases.”
So what does he want? Some things that Britain has – or had. GPs to act as universal gatekeepers to limit use of specialists; a Nice to make sure all drugs and treatments are effective and good value; and less doctors’ time and money wasted on bureaucracy and bills.
“And please, no more politically motivated reforms for a while.”
http://www.guardian.co.uk/world/2011/mar/16/german-health-warning-doctors-paperchase