Lauterbach's exit from coal: hospital reform must create a paradigm shift

Minister of Health Lauterbach is gradually presenting the parts of his hospital reform.

Lauterbach's exit from coal: hospital reform must create a paradigm shift

Minister of Health Lauterbach is gradually presenting the parts of his hospital reform. It's about fewer and better clinics, about money and about the principle. This raises many fundamental societal questions.

In 2019, the Bertelsmann Foundation compared the hospital reform with the coal phase-out. "The conversion is to be understood as a transformation of society as a whole for entire regions," wrote the experts in the paper, which was intended to clarify whether Germany could not significantly reduce the number of its hospitals. The verdict was clear: Instead of the more than 1,600 hospitals today, only about 600 are needed, divided into regular and maximum care providers, according to the assessment.

Three years later, Health Minister Karl Lauterbach began implementing the hospital reform. It's a mammoth task. Hospitals can hardly finance themselves, but have to take care of an aging society with fewer staff. For years there has been criticism of the flat rate per case and the quality of medical treatments. In the future, Lauterbach wants to give medical aspects more weight than economic ones. This means the end of case flat rates, those flat rates introduced in 2003 for comparable treatments.

The medical director and chairman of the board of the University Medicine Essen, Jochen Werner, is nevertheless disappointed: "The planned measures are far from sufficient to make the health system and its hospitals medically, organizationally and financially future-proof," he writes in an assessment. Key points of the reform have already been decided: there is more money for child care, more outpatient treatments should reduce the number of overnight stays in the clinic. A new instrument for staffing is to be based on calculated ideal staffing for the stations.

Werner welcomes the suggestion that more treatments be carried out on an outpatient basis. "I am very much in favor of only bringing people to the hospital who really belong in the hospital," said Werner So far, the implementation of this well-known idea has always failed because of the remuneration.

It is now planned that certain clinical examinations and treatments lasting at least six hours can also be billed by the hospitals without an overnight stay. The future "equal sector" remuneration lies between the outpatient and inpatient level. Because fewer night shifts then have to be manned, more nurses could be employed during the day. In the Bertelsmann study, the number of patients who could just as easily be treated or operated on as an outpatient was estimated at around five million. "That alone corresponds to around 500 medium-sized hospitals or a third of the capacity of all German general hospitals," according to the experts in 2019.

Werner, who has just published a book about his ideas for the hospital of the future, is keeping a close eye on developments. It has long been clear that the small-scale hospital landscape has no future. "We can't avoid reducing hospital beds. There are a number of houses that are barely viable." But every decision leads to more. Should a hospital be closed or rebuilt to work more efficiently in the future? What do you do with hospitals that are not being continued? Do you rebuild in the same or a different place? Are you investing in climate-neutral and sustainable buildings at the same time, which may be more expensive now but will save costs in the long term?

"It's always about the money," says Werner. However, not every money-oriented solution eliminates every problem in the hospital. This becomes very clear in the day hospital stays. On the one hand, without the overnight stay, there is no getting used to the new environment, which is often problematic for older people in particular. The shorter you are in the hospital, the lower the risk of contracting germs that you are exposed to in the hospital in the first place. A stay in hospital also gives security, especially for people living alone, simply because there are caregivers there.

Werner wishes "that patients who have to receive hospital treatment because they are so ill that they cannot be treated on an outpatient basis are provided with care, time and care". For him, this human side also means "that we can use all the knowledge we have about these patients". We are talking about the electronic patient file, which has been available to use voluntarily since January 2021, but which should now become the norm unless expressly contradicted. For a long time there was a dispute about data protection aspects, while double and triple examinations and their burdens on health budgets and patients were much less discussed, as was the lack of or less successful treatment due to loss of information.

The closure of maternity and neonatal wards in small and medium-sized towns has shown how emotional people get when it comes to their local hospital. "People are worried that there won't be a hospital nearby that can take care of you when you're sick," says Werner. "What we have to convey is that it's not the house that matters, but the place where they get the best possible treatment for their illness." This is not always guaranteed in the small hospitals. According to the Bertelsmann study, 57 percent of all German hospitals are small clinics with fewer than 200 beds. Many are not adequately equipped with medical technology and have too few specialists.

Werner took important insights from the often heated debates on the maternity wards. It takes a lot of mediation of such decisions and: "You should trust the results that science provides. In obstetrics, it is clear that the quality correlates with the number of births. That is not mentioned at all, but above all it is not very important in such simple births. You need experience, equipment, staff."

Werner does not doubt the competence of the Minister of Health. Nevertheless, the reform plans give him headaches. "Lauterbach only has four years. But what we need is a development program over ten or fifteen years that as many political parties as possible agree on and then follow this path with commitment." It would have to be thought of nationwide, without failing at federal borders. From Werner's point of view, the university hospitals should also be involved in order to enable new treatments through research.

In order to really make hospitals fit for the future, Werner sees a need for reform far beyond the clinics. What about the people before the practice or hospital treatment, i.e. with prevention? What about after the hospital and after rehabilitation? How are job descriptions developing in the healthcare industry? "It's about an awful lot, in terms of health and the economy."

The comparison with the coal phase-out no longer seems exaggerated. But many were involved in the coal exit, Lauterbach has to drill this thick board above all alone. Even more than Corona, the reform is perhaps the most important project of his term. The move away from the flat rate per case is a paradigm shift that can keep up with the farewell to Hartz IV.