Buses: "More staff is the worst answer"

Never tiring of explaining again and again the basic considerations that form the basis of hospital reform, Prof. Dr. Reinhard Busse, MPH, FFPH (Technical University of Berlin) answered questions from many listeners at the “Reconstruction of the Hospital Landscape” event at the HSK. They included many hospital managers who - a few weeks before Lauterbach's commitment to introduce revenue-independent retention allowances - were united by two big questions: Does it affect me? And why? His answer was quite simple, even though there are two narratives and two parallel problems. Daniela Teichert, the chairwoman of AOK Nordost, however, called for a bigger look at the whole thing.

>> Now that the hospital reform, which, as a fellow discussant at the HSK event argued, is more of a hospital financing reform, is entering the home straight, he – according to Busse – wants to “drive in a few pegs”. He did this in his usual manner with a look abroad. However, this is not because we want to copy what is happening there, but rather to be able to better reflect on our own position.
The all-round view drawn by Busse, which the OECD Health Report “Glance 2021” he uses makes it possible for anyone who wants to know, is quite something. In the three-year overview, Germany is at the far left of the table (Fig. 1). Busse: “We are an extreme case when it comes to beds when you compare us with countries like Switzerland. The Swiss have 33%, the Danes 40%, the British 50% and the Dutch even 64% fewer cases being treated in hospitals.”
But this is only because, says Busse, there are a lot of hospitals in this country, but also a lot of inpatient beds and inpatient cases that are treated. Here, according to the doctor and economist, he is faced with the question: “Which came first, chicken or egg?” What Busse is simply referring to is supply-induced demand. Many cases treated in clinics with main diagnoses such as hypertension, diabetes or heart failure cannot be explained otherwise, and his foreign colleagues would ask him: “What are they actually doing in your hospital?”
His answer is as sober as it is sobering, which leads to one of his two narratives: On the one hand, you are unnecessarily exposed to hospital germs and you also unnecessarily tie up staff. Busse: “And this despite the fact that we have the third-most nursing staff in Europe – calculated per 1,000 inhabitants – after Finland and Ireland.”
Narrative and problem 2: There are simply too many hospitals in Germany. This in turn leads to cases that are both unnecessary and necessary being spread across too many clinics, and often to clinics that are not adequately equipped.
In order to understand the drama behind this statement, Busse looked at the current hospital landscape, in which almost 60% of cases were treated in emergency level 3 and 2 hospitals. The classification according to emergency levels is based on an adjusted 1,700 locations that (as of 2021) care for a varying number of cases:
• 164 at level 3 (9%) and 5.0 million (31%) cases = 84 per day,
• 261 at level 2 (15%) and 4.2 million (26%) cases = 45 per day,
• 647 at level 1 (37%) and 5.3 million (33%) cases = 22 per day
• 657 other (38%; including specialist hospitals) and 1.7 million (10%) cases = 8 per day

Nevertheless, Busse continued, most hospitals “care” for almost all indications, despite often inadequate equipment, which is why he also put the verb “care” in quotation marks. Why he does it this way becomes clear when we take a closer look at the quality of the outcome it produces. He gave some examples:
• Heart attack: With an incidence of 500 cases per day, patients with transmural heart attacks are treated in over 1,000 hospitals, with only 578 having a left heart catheter.
• Cerebral infarction: With an incidence of 600 cases per day, patients with cerebral infarction are treated in over 1,100 hospitals, although only 475 have a stroke unit.
• Pancreatic cancer: Despite minimum volume regulations, 23 hospitals in Berlin alone carry out complex pancreatic procedures, although only 7 have a pancreatic cancer center; In 2019, there were over 70% in pancreatic cancer outside the 117 pancreatic cancer centers (Source: German Cancer Society, 2020)
• Cancer: Over 50% of all cancer patients are treated outside cancer centers, but many centers also have very low case numbers. 30 of 60 pediatric oncology centers have fewer than 40 patients per year (source: Ebinger et al., Deutsches Ärzteblatt).
Busse made it more than clear with an example what this universal care entails: “We know from studies that the one-year mortality rate in homes with a stroke unit is 23%, but in clinics it is 30%.”
Now many would say that a lack of quality is primarily due to a lack of staff. More staff, says Busse, is the worst answer that could be given. What would it help if there was an oversupply of beds and more nursing staff? Who is supposed to do that, please? 2020 was always heralded as the year in which the demographic transition would really take hold. Now everyone thinks it has something to do with Corona, even though that was clear decades before. This means nothing other than that the personnel shortage will become significantly greater than it is today. Already this year around 1.2 million people are 66 years old and older, but only around 700,000 people are 20 years old. Busse: “These 1.2 to 1.3 million people will soon be retiring, but the next generation is only half as large, which costs us around 600,000 jobs every year.” The healthcare system already accounts for a seventh of all jobs included. One could easily calculate that the demand for more staff would be ruled out. Busse: “We have to take into account that we are now probably at the peak of the health workforce.”
The second demand, which is made all too easily, especially by the federal states, is for more money. Here, too, he made a clear rejection: “Wanting to solve problems with more money is out of the question!” Germany is already spending a lot of money on inpatient care in relative and absolute terms compared to international standards, and on top of that, it is significantly increasing. The share of the gross domestic product that is spent on inpatient care in this country has increased from 3% (2010) to 3.4% (2020). In Denmark, however, the share of GDP increased from 3.2% to 2.8% in the same period after the hospital reform that had already taken place there
sunk.
In the panel discussion following Busse's lecture, which also included Dr. Dirk Albrecht (Contilia GmbH), PD Dr. Thomas Menzel (Klinikum Fulda gAG), Prof. Dr. Dr. hc mult. Jens Scholz, MBA (University Hospital Schleswig-Holstein) and Daniela Teichert (AOK Nordost) took part, it became clear that Busse's statements were not necessarily shared by everyone.
However, a fellow discussant noted that, in his opinion, performance groups better reflected the reality of care and, thanks to the combined level classification, represented a good instrument for control. In this respect, these efforts should be supported. However, he also critically noted that a pure hospital reform was not enough, as in principle it was only a reform of hospital financing. His petition: “We actually need a holistic approach, from emergency care to outpatient care with statutory health insurance.” It is urgently necessary to approach health care as a whole.
Daniela Teichert, the CEO of AOK Nordost, saw it very similarly. At night she sometimes dreams of a holistic health system that distributes resources according to the required quality, but still enables quality competition. However, her job during the day is, among other things, to convey to her colleagues “that we can no longer work the way we did in the past.” By this she means the previously sectoral and annual supply planning, which must be transferred to a planning horizon that extends to 2030 and beyond. <<