Problems common to the United Kingdom and Germany in delivering health care were addressed at a meeting in Potsdam, Germany, on September 11 and 12, organised jointly by the UK’s Royal Society of Medicine and Germany’s Gesellschaft für Versicherungswissenschaft und Gestaltung (association for social policy research and development). The meeting attracted health professionals, health care administrators, economists and legislators.
Speakers at the joint British/German meeting placed particular emphasis on the problem of rising costs and expectations in the light of limited resources and how to find solutions acceptable to the public and affordable to government. Early speakers set the scene by describing the UK and German health care systems. Their addresses made clear that, although the two systems were run on different lines, they now had to cope with similar issues. These included the increase in technical developments and a growing proportion of elderly people, both of which made it difficult to work within limited resources.
Beveridge model
Comparing the UK system with the German one, Dame DEIRDRE HINE (president, Royal
Society of Medicine) described the National Health Service as a “Beveridge
model” where health care was financed mainly by general taxation and delivered
under the supervision of a central public institution. General taxation accounted
for 80 per cent of NHS funding, and although a lot of people in the UK thought
that the whole of the NHS was funded by payment of national insurance, in reality
this latter source accounted for only 12 per cent of funds.
The NHS was experiencing a degree of revolution at the present time, but the
principles which made it distinctive — ie, that it was funded from general
taxation, free at the point of delivery, accessed through primary care and provided
prevention and treatment — still remained. The NHS was still the most treasured
of all the UK’s welfare systems, but at its inception it had been flawed
in one major aspect: the belief that universally available health care would
reduce demand. Clearly this had not been realised.
Per head of population, Germany spent more on health care than the UK and also
had twice the number of doctors, twice the number of nurses and twice the number
of hospital beds. Such figures made the UK appear poorly resourced and under
strain. Long waits for elective treatment, which were unknown in Germany, a
worrying difference in care between different UK regions and different social
groups, a series of medical scandals, and rising disquiet among patients, often
as a result of increased knowledge about health care in other European countries,
tended to confirm this picture.
The NHS had gone through a series of changes over the years, including clinical
governance, the National Institute for Clinical Excellence, the Commission for
Health Improvement, primary care groups, primary care trusts, NHS Direct, NHS
walk-in centres and, most recently, a new national plan for the NHS had been
developed. While a commitment to funding through taxation remained, at the heart
of the NHS plan was the recognition that the service needed more money. Funding
was therefore planned to increase by a third over the next five years to bring
UK health care spending in line with the EU average. This would lead to 7,000
more beds, 1,000 more medical students, 2,000 more GPs and 2,000 more nurses.
Other features of the NHS plan included: a modernisation agency to spread best
practice; new consultant/GP contracts; extending the nurse’s role into
hospital admissions and prescribing; bridges between trusts and social care;
increasing patient empowerment in the form of patient advisory and liaison services;
concordance with the private sector; and earned autonomy for trusts that performed
well.
There were also targets such as no more than a four-hour wait in accident and
emergency units (by 2004), all admissions booked (2001), outpatient waiting
time down to three months (2005), and inpatient waiting time reduced to six
months (2005) and three months (2008). Such targets would be unnecessary in
Germany, where long waiting times were unknown, but for the UK the targets were
so dramatic that there was scepticism as to whether they could be achieved.
Bismarck model
Professor JÜRGEN WASEM (chair of health systems management, Greifswald
university, north east Germany) said that the German system operated according
to the “Bismarck model” — a model for social security with compulsory
health care insurance under which insurance funds might be independent of government.
About 90 per cent of the population were covered by public health insurance,
and the system was competitive in that patients could choose which health insurance
company to belong to. In addition, about 10 per cent of Germans were covered,
partially or wholly, by private health insurance and there were few people without
any kind of coverage.
Companies competed on the basis of contribution rates, and this resulted in
1-2 per cent of people shifting between companies each year. All public companies
had non-profit status and were based on the principle of self-government. However,
according to Dr FRANK ULRICH MONTGOMERY (Ärztekammer [chamber of physicians],
Hamburg), insurance funds in Germany were not independent. They were regulated
by government, as the passing of 50 major bills through parliament over the
past 20 years had indicated.
High expenditure
Health care expenditure was about 11 per cent of gross domestic product (GDP),
which was among the highest in the world. In Britain the equivalent figure was
6.5 per cent and the European Union average was 8.5 per cent, although caution
had to be exercised in interpreting these figures because they could be calculated
differently. Nevertheless, the trend of high expenditure in Germany was evident
and this was due partly to extension of the West German health care system to
the east after unification to replace East Germany’s former Soviet-style
system. Health care costs in the eastern part of the country represented more
than 14 per cent of East German GDP.
Unlike East Germany, where there had been a huge change in the system of health
care delivery between 1945 and 1989, and even in comparison with Britain, West
Germany had experienced remarkable stability in its health care system. Revolutions
had rarely occurred, and most developments were incremental. However, this was
largely due to the fact that there were many participants in the German health
care system — in both legislation and implementation. At the political
level, responsibilities were divided between the federal level and the 16 states
(Länder), but at a non-political level, there were many semi-public and
semi-private participants, and this meant that, in practice, it was difficult
to change the system.
There was a common understanding in Germany that health care services were rather
fragmented, Professor Wasem continued, and that this was one of the reasons
for the high cost and in some areas, relative inefficiencies. For example, there
were two types of doctors working in the community — general medical practitioners
and office based specialists — and they competed with each other for patients.
Unlike the UK, Germany had no “gatekeeper” system. Although the government
had tried to strengthen this, and many people would say that they had a “family
doctor”, in practice it was still an open system in which patients could
go and see any doctor they wanted. Moreover, co-operation between doctors in
hospitals and those in the community was weak.
According to Dr MONTGOMERY, the main reason for this lack of co-operation was
separate budgets for the different sectors. Transference of money from one budget
to another was difficult, and there had to be proof that service had been transferred
along with the money. “Cake graphics” was a big problem in Germany,
with everyone wanting to defend his or her slice of the budget. A variety of
methods to improve co-operation had been suggested, but little progress had
been made towards achieving them.
According to Professor WASEM, while most health care providers believed that
problems could be solved by putting more money into health care, most politicians
believed that contributions to health insurance should be stable and should
not grow faster than salaries and pensions, etc. This had led in Germany to
various cost containment measures, which strengthened the insurance companies
in their bargaining power with health care providers and also increased co-payments
for patients.
But it was only recently that prioritisation of health care services had become
an issue in Germany. Traditionally, the philosophy has been that everyone should
be entitled to all the necessary services and that doctors decided what services
were necessary for their patients. However, “rationing” was now being
discussed and two central committees (one for community and one for hospitals)
had been set up to identify which services should be provided. How strong these
agencies would become was unclear.
Increasingly, quality was also becoming an issue, and a joint agency for quality
in health care had also been established. In general, reporting about quality
was underdeveloped in the German health care system, and transparency about
the quality of individual health care providers was only anecdotal. This was
in contrast to the US system, and increasingly to the UK system, where “everything
was known”.
Targets
Professor NICK BOSANQUET (professor of health policy, Imperial College, University
of London) explained how the UK had set various health targets, including the
Health of the Nation targets in the 1990s. Although the programme had had some
successes, targets involving behavioural change such as reducing weight and
stopping smoking had not been achieved. Nevertheless, the Health of the Nation
had stimulated the development of new patient groups and critical perspectives
on health care.
In the past three years, however, the Government had reduced the number of health
related targets, claiming that the old targets took no account of the influence
of environmental and social issues on UK health. The focus had therefore shifted
from outcomes of disease to a system of performance management standards, where
outcome, although still there, was much less visible and process has been given
more emphasis. Ironically, the end result had actually been a shift away from
the wider determinants of health to access and function of health services at
a local level. However, hope now existed for a more local agenda for achieving
health outcomes.
The situation in the UK contrasted with that in Germany where, as explained
by Dr REINHARD BUSSE (leader of the Madrid office of the European Observatory
on Health Care Systems, Spain), there were no national health targets. Although
objectives for health were written into the German social code book, no level
of government had authority over all potentially relevant areas. This was because
responsibility for health care was split between the federal level and the 16
states. Another factor was poor co-operation between primary care and hospitals.
Health targets had been introduced in some areas, notably North Rhine-Westphalia,
and it was possible that they could also soon be established at a national level.
Conclusion
In her closing remarks, Dr SIBYLLE ANGELE (GVG, Cologne) emphasised that health
professionals needed to be aware of the differences in health and health care
in each other’s countries and what they could learn from each other. The
health care systems in the UK and Germany had some common features, some similar
achievements and some common problems — with the emphasis on the word some.
In summary, the UK NHS was funded by general taxation, rather than from the
system of social insurance used by Germany. Although there had been increases
in charges to patients (eg, medicines, dental and ophthalmic services, long
term care for elderly people), most primary and secondary care was still provided
free at the point of delivery. And despite various funding crises there had
as yet been no serious attempt to move away from a system of tax based funding.
However, many management and organisational changes had affected the way services
were delivered and the Government had established an agenda for developing the
NHS in collaboration with other agencies. But how successful this agenda would
be in increasing efficiency, equity and quality was not yet clear.
The German system put more emphasis on free access, high numbers of providers
and technological equipment than on cost effectiveness or cost containment per
se and waiting times and explicit rationing decisions were virtually unknown.
Health care expenditure as a proportion of GDP was relatively high compared
with that in Britain. A weakness of the German system was fragmentation between
primary care and secondary care, and the limited role of primary care and absence
of gatekeepers (eg, GPs) to steer patients through the system.
A pan-European perspective
Providing a pan-European perspective, Professor MARTIN McKEE (professor of
public health, London School of Hygiene and Tropical Medicine) pointed out that
policy makers across Europe were increasingly recognising the European dimension
to their work. Although health care had been excluded from the Maastricht treaty,
developing European law had a growing impact on health care. This was not only
on the few laws that related specifically to health, but also the impact of
policies in other areas such as employment, insurance and trade. For example,
the pharmaceutical labelling directive had encouraged price increases in generic
medicines, simply because the requirement to include a patient information leaflet
meant that generics could no longer be dispensed from bulk but largely in patient
packs. The advent of patient packs for generics reduced some of the price differential
between generics and branded medicines.
Dr HANS STEIN (specialist at the German federal ministry of health) pointed
out that the EU was not only about unification of countries but also about unification
of people and cultures, and the differences had to be understood. As an illustration,
some European countries (eg, Germany, the Netherlands, Austria and Belgium)
operated health care delivery according to the Bismarck system while others
(eg, the UK, Denmark, Sweden and Spain) applied the Beveridge model. Health
expenditure varied between countries as did patients’ satisfaction with
their national system.
In the light of these differences was there any point in seeking a common purpose?
How much was the EU needed for health? Growing communication between countries,
such as the UK and Germany, could help to shape the content of EU health activities,
but there was a limit to this because each country had to decide how much it
wanted an EU influence on national health care and where it wanted to draw the
line. One reason the European Commission was considered to be so strong was
the perceived weakness of the member states, which tended to defend positions
that were not even being attacked.
The situation was changing gradually as member states started to recognise and
even partly accept the European influence. But it was still easier to criticise
European institutions than to proactively develop initiatives in areas such
as evidence-based medicine, health technology assessment and quality assurance.
Member states needed to think about the areas where they wanted to retain control,
such as access to and financing of health care. Given that, it should then be
possible to achieve consensus as to how health systems could be improved with
“European added value”.