„We no longer have time to lose. It is now all the more important that we address the structural financing problems in statutory health insurance and long-term care immediately. Our goal is to find a balance between revenues and expenditures,” explained Nina Warken, the Federal Minister of Health in the current coalition government, during her seven-minute appearance at this year’s Berlin Capital Congress. The diagnosis seems clear: The patient – the German healthcare system – has been suffering for many years from chronic anxiety, apathy, and an increasing loss of control. The existing treatment strategy – consisting of years of superficial, short-term solutions, minimally invasive reforms, and quick cash injections – appears to have failed. A comprehensive business process reengineering – essentially a radical cure – of the German healthcare system through a primary care model could lead to recovery.

„An expert commission will be established for the statutory health insurance system to develop proposals for stabilizing contribution rates in the short, medium, and long term,” Warken explained. She also pointed out, however, that the current government's coalition agreement stipulates these proposals should not be available until 2027. Warken's conclusion: „But that is clearly too late for me. We need results much sooner.” Therefore, she has given the commission a corresponding mandate and established the federal-state working group „Future Pact for Long-Term Care.” By the end of the year, joint key points are to be presented for the sustainable financing of long-term care insurance, the strengthening of outpatient and home-based care, and simple, streamlined access to long-term care insurance benefits for those requiring care and their families. In parallel, structural reforms are already being developed to improve efficiency on the one hand and contain costs on the other, with the goal of ensuring good, needs-based, and affordable healthcare and long-term care „for everyone, comprehensively, in both urban and rural areas, regardless of postal code.”.
Sandra Postel, president of the North Rhine-Westphalia Chamber of Nursing, criticized Federal Health Minister Warken's use of the terms "healthcare and nursing" in her opening speech at the Bosch Health Campus GmbH HSK satellite symposium on "Rethinking Healthcare in Rural Areas." She said, "I stood there and thought: We nurses are healthcare." This perceived separation must finally be overcome. Tahnee Leyh, a community health nurse with the German Red Cross (DRK) Fläming-Spreewald district association, also described her profession—or rather, her calling—as a "jack-of-all-trades" at the Bosch symposium. With her nursing expertise, she must cover many different areas, from general advice, health promotion, patient management and education, including helping patients to find their own way through the health system, and finally, co-care for patients up to the rehabilitation area.
This list, which is by no means exhaustive, gives an idea of how diverse a comprehensive healthcare system can be from a broader perspective.
of nursing. However, this perspective is new, at least in this country, as our healthcare system has so far always been conceived and planned solely from the perspective of the medical profession – whether in private practice or working in hospitals.

Alscher: new forms of supply and truly creative ideas
„The minister said earlier: regardless of the postal code. I would add: also regardless of the structure and regardless of whether someone lives in a large city or in the countryside,” said Prof. Dr. Mark Dominik Alscher, Medical Director of the Robert Bosch Hospital and CEO of the Bosch Health Campus since 2016, introducing a new approach. In his view, such a promise of care can only be fulfilled if new forms of care and truly creative ideas are given a chance. His warning, which he issued at the HSK Symposium of the Bosch Health Campus, was: „If we remain within the old structure, we must realize that we will perish because the existing healthcare system is simply no longer financially sustainable.”
But there is hope, as demonstrated by the Bosch Health Campus. The former health division of the Robert Bosch Foundation, which had provided numerous impulses for healthcare over many years, was deliberately integrated into the campus to test new forms of care and develop practical solutions for the upcoming changes in healthcare. This is what personally convinces him that "it can succeed" if a "new way of thinking" takes hold.
This is new because, in addition to telemedicine in both rural and urban areas, patient-centered primary and long-term care (PORT) centers must be established. Such primary care centers already exist as pilot projects in Berlin-Neukölln, Brüggen, Büsum, Dachau, Darmstadt-Dieburg, Hamburg-Veddel, Hohenstein, Hülben, Kassel, Märkische Höhe, Stuttgart, and Willingen-Diemelsee (1). They are considered pilot projects because these PORT centers—designed to ensure comprehensive basic care for the population in various regions and to provide better, integrated care for chronically ill individuals—are funded by the Bosch Health Campus, a subsidiary of the Bosch Foundation, as funding for such pilot projects has not yet been available. This is because Alscher still hopes for corresponding legislative proposals, which were initiated by the previous federal government but never finalized. Patient-centered centers are crucial, however, because primary care will no longer be viable in light of the challenges ahead. In PORT centers, however, other health professions would also be integrated, with a community health nurse acting as coordinator rather than a doctor – in acute care, but also in prevention.

Karagiannidis: Deductible of 200 to 600 euros
Why primary care will no longer function adequately was explained at the HSK satellite symposium by Prof. Dr. Christian Karagiannidis, head of the ARDS and ECMO center of the lung clinic of the Cologne-Merheim hospital and holder of the professorship for extracorporeal lung replacement procedures at the University of Witten/Herdecke.
Karagiannidis, who, along with Alscher and Prof. Dr. Boris Augurzky, co-authored the book "Health of the Future", assumes that the topics of the primary care system and emergency care, as well as the recently presented draft of the Nursing Competence Act, will be widely discussed in the next 12 to 24 months.
He explained his reasons for this by citing a few key facts. Firstly, he stated that around a third of all rural districts in Germany would soon be at risk of lacking primary care. Secondly, the looming shortage of general practitioners would coincide with an "unbelievable number" of doctor-patient contacts, which, in his view, was unjustifiable. He spoke of a staggering one billion doctor visits per year, or 12 per capita. This, he argued, was a burden that urgently needed to be reduced. He cited numerous minor ailments and a declining health literacy among the population as contributing factors.
While he found the primary care system outlined in the coalition agreement to be very good, he said it was essential to discuss in the coming months how to "somehow manage these one billion doctor visits." After all, a primary care system inevitably means an increase of approximately 100 to 150 million additional contacts for general practitioners.
Nevertheless, he considers a primary care physician system a good solution, as Germany is one of the very few countries in the world that currently does not have one. He added that the team led by Professor Dr. Leonie Sundmacher had written a "very good paper" on this topic, which he also presented at the HSK Symposium. (Editor's note: Incidentally, it was first published online on the portal (2) of "Monitor Versorgungsforschung" and can be read in this issue starting on page 53.).
According to Karagiannidis, this article analyzes where primary care systems exist worldwide and how they differ. While the French system is generally closest to our German one, there is no system in the world where patients have truly free access to specialists. And where they do have such access—as in Scandinavian countries or France—it always involves a certain co-payment or contribution, which we don't have in Germany.
If a truly person-centered primary care system is to be introduced in Germany, then, in his view, the delegation or substitution of services must be discussed, as well as independent treatment by nurses or physician assistants. These are two approaches currently developing in Germany, and both will continue to exist in parallel. However, they have been active in Spain and Portugal for some time, as their primary care systems include not only physicians but also independently practicing physiotherapists, community health nurses, and physician assistants (PAs). These are different approaches that—if a primary care system is to be incorporated into legislation—must also be regulated with regard to professional and benefit regulations. "We can't just say that nursing is given more competencies; we also have to say how this will all be reimbursed, otherwise it won't work," Karagiannidis explained.
Taking into account the additional doctor-patient contacts inherent in a primary care system and the urgently needed regulations regarding professional and benefit law, one should rather "take a little time with it." Also, because he does not consider such a law to be particularly time-sensitive, and because the development of nursing expertise and the necessary training positions will also take time, he anticipates a duration of a full decade.
Therefore, Karagiannidis sees co-payments as the most effective lever, even though they are by far the least politically appealing. He isn't thinking of a simple co-payment, which would have created a lot of bureaucracy without any real effect, but rather a genuine out-of-pocket expense for patients amounting to 200 to 600 euros per year: "We should introduce this, especially since we are one of the last healthcare systems in the world that doesn't have it." This would lead to the desired effect: "People would only go to the doctor when they really need to." This would finally eliminate the minor ailments, which he estimates account for at least 20 percent of doctor-patient contacts in Germany.
Another law inextricably linked to the concept of primary care, according to Karagiannidis, concerns how patients can be managed much more effectively through the system in emergencies. He stated that this is something we are not yet managing optimally, despite the fact that a corresponding proposal had been submitted by the government commission and a hearing had taken place in the Bundestag, where there was broad cross-party agreement. Karagiannidis added, "I have rarely experienced anything like that in the Health Committee."„
The absolutely crucial element is the role of a dispatch center coordinator, who will assume a pivotal position in the healthcare system in the future. After three years of training, a dispatch center coordinator can ensure that not every patient is taken to the hospital by ambulance, but rather is directed to the facility where they can receive the best care. This could also mean scheduling an appointment with a general practitioner. "I consider this law at least as important as the one for a primary care physician system," said Karagiannidis.
This requires integrated emergency care centers at the hospital level, which are already functioning "very well" in some regions. For example, an evaluation of a Frankfurt hospital after the introduction of an integrated emergency care center showed that the number of emergency room visits decreased by 50 percent, which is considered "truly substantial." According to calculations by the government commission, however, 425 such integrated emergency care centers are needed in Germany. The National Association of Statutory Health Insurance Funds (GKV-Spitzenverband), on the other hand, would like to see 800 to 900. While this would be "certainly desirable," they do not believe there are enough staff available to staff them.

Postel: Care aids and home nursing care outside the scope of medical practice
Who better to address these substantive issues than Sandra Postel, president of the North Rhine-Westphalia Chamber of Nursing? As head of Germany's youngest chamber, established only in 2022, she now has to make up for at least 70 years of self-governance; and all this within a conservative system where nursing as a profession has yet to be fully embraced. "Of course, we're trying to get into the machine. This sometimes leads to glitches," she said regarding the current state of her work, in which nursing has not yet fully grasped all the "mechanisms in this large political engine room." Her fledgling chamber of nursing must act as an equal partner in self-governance, creating and enforcing professional law, a code of conduct, and continuing education regulations.
After this foray into the harsh reality of establishing a professional chamber, she presented three theses, relevant to the recently published draft of the Nursing Competence Act. "Nursing is capable of more than it is currently allowed to do," she said, echoing a slogan from last year. To change this, a new [legal framework] is needed.
The framework of current legislation, which must be considered together at the federal and state levels, encompasses professional law, nursing competence law, benefits law, and professional law. For example, in France, it is clearly regulated that 60,000 independent nursing professionals in competence centers—dedicated nursing practices—assume responsibility in the form of municipal support. Postel: "In France, nurses, driven by a strong professional ethos, clearly see themselves as public employees." And they quite naturally take on tasks that, in Germany, are reserved for physicians, such as prescribing assistive devices and home nursing care. Postel's question regarding the German system: "Why is this even reserved for physicians?" It should be logical that nursing professionals are best positioned to make judgments on the issue of care needs. Removing prescriptions for assistive devices and home nursing care from the physician's purview would therefore be, in her view, a "first pragmatic step" that would allow nursing to assume a crucial component of primary care, which, of course, would need to be "thoroughly discussed and implemented.".
This statement led the president of the North Rhine-Westphalia Chamber of Nursing to her next point: "We currently have no overview of nursing professionals in Germany." While the state of Bavaria has begun registration, North Rhine-Westphalia is currently the only state with the "most concrete and comprehensive register" in Germany. This, too, is an important function of a chamber: providing the necessary data. In crises and disasters, but also in the "daily business of a billion doctor visits," Germany needs to be better positioned in this regard than it is now. That is why she couldn't understand why such a register hadn't been included in the coalition agreement. Postel: "We need much better data on nursing to implement everything necessary if a primary care and primary physician system is to function."„

Leyh: Intercept 20 percent of minor illnesses
One woman who is already doing what is possible within the current legal framework is Tahnee Leyh. Having created the position herself, she is employed by the German Red Cross (DRK) Fläming-Spreewald district association as a community health nurse for the Luckau area. She is called a health nurse because the term "community"
The role of "health nurse" seemed difficult to implement in rural areas. She sees herself as "the spider in the web," providing primary care and general medical support, while also considering the broader social context. "I can soon take over precisely those 20 percent of minor illnesses that my colleagues at the GP clinic can no longer handle," she asserts. Because, as she points out, "I'm already doing that." However, she faces the same problem that Sandra Postel already mentioned: "For every repeat prescription, every home care order, and every wound care request, I have to run to the GP clinics." And this is despite the fact that they would gladly delegate these tasks to her. Leyh, who works at the interface between the social environment and the municipality, explains: "I'm the one who's very close to the families, who sees their needs, and can even diagnose and provide support."”
During home visits, which constitute the majority of her work, she identifies needs and, in doing so, also knows where the social hotspots are in the predominantly rural community. She doesn't keep this knowledge to herself, however, but communicates the identified needs to the town council and the school and social affairs committee. She also maintains regular contact with the county health department. Therefore, she sees herself as an advocate for the patients, combined with leadership and management skills.
by: MVF editor-in-chief Peter Stegmaier