Between money and staff shortages: What's next for Saxony's hospitals?

The hospital reform planned by the federal government is supposed to improve everything: better treatment quality, fewer interventions for purely financial reasons, less paperwork. But experts are warning of the opposite - a noticeable deterioration in medical care. "We are still living on the island of the happy," says Josef Hecken.

He is the head of the Joint Federal Committee, the highest self-governing body in the German healthcare system. "In times when the money was flowing, new services were always being decided. We didn't take into account where we were heading: In 15 or 16 years, there will be 5.2 million more multimorbid people in Germany, but six million fewer people who are able to work - and therefore fewer doctors and carers to look after them."

It is good that medical and technological progress is enabling people to live longer. There are already more than 1,300 over 100-year-olds in Saxony today. "But the key question for the future is: how can the growing morbidity burden be reconciled with the increasingly complex need for treatment in rural regions and financed under socially acceptable conditions?"

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Contributions at record level

Healthcare expenditure continues to rise. This year, the statutory health insurance funds will spend over 90 billion euros on hospitals alone. At the same time, contribution rates for the insured have reached an all-time high. As of 1 January, not only the income threshold but also the additional contribution is set to rise again. Health Minister Karl Lauterbach (SPD) has ruled out any cuts in benefits.

His hospital reform is intended to fix the situation and better dovetail inpatient and outpatient care. However, Josef Hecken assumes that the reform law will not come into force in January as planned, but on 1 April at the earliest. "There are still too many unanswered questions," he said at a specialist event organised by the Techniker Krankenkasse Sachsen in Dresden. In November, the minister presidents will therefore be heard once again in Berlin.

Time is pressing. According to a survey by the German Hospital Institute, almost 70 per cent of German hospitals believe that their existence is at risk. "We have already undergone structural change in Saxony," says Friedrich München, head of the Hospital Association of Saxony. "But there is also great concern in our 76 hospitals. Because they are suffering from chronic underfunding." The main problem is the increase in personnel costs, which according to Hecken account for around 65 per cent of hospital expenditure, but also higher material and inflation-related costs.

200 million euros missing

The Paracelsus Clinic in Reichenbach, Vogtland, was the first hospital in Saxony to have to close due to insolvency at the end of March. Other clinics are not covering their costs, partly because the number of cases has fallen. "For 2024, we expect Saxony's hospitals to be around 200 million euros short in operating costs alone," says München.

The state of Saxony does not want to wait until the federal government's hospital reform takes effect. This is because the implementation of structural changes will take several years. A new hospital plan for the Free State is to come into force on 1 January, which will set the course for the future "evolutionary rather than revolutionary", as Dagmar Neukirch, State Secretary in the Saxon Ministry of Social Affairs, explains. The biggest challenges are the declining but ageing population and the shortage of skilled labour. It must be possible to ensure good basic care across the board and at the same time allow all citizens to participate in medical progress. Neukirch: "Accessibility is an important quality criterion for us." However, not every clinic can offer the highest levels of treatment.

Not everything affordable anymore

Hecken, head of the Federal Committee, speaks of a balancing act between basic and specialised care. "Not everything is affordable everywhere. And the closest clinic is not always the best." This is because scientific evidence shows that mortality increases for many procedures if the number of cases falls below a certain minimum.

Hospital planning is a national matter. However, Hecken appeals to political leaders and the population to support painful decisions in the face of medical facts - even if the next election is imminent. "For example, there is currently an uproar against the fact that from January, babies weighing less than 1,250 grams may only be treated by hospitals that have at least 25 such cases per year instead of the previous 20," he says. Wouldn't a perhaps longer journey to such a clinic be justified if more of these premature babies survived?

Hundreds of doctors are retiring

In future, legally prescribed care levels and service groups will regulate what is offered at which hospital. Some hospitals will have to downsize, others upsize. The details are still being worked out at federal level. "However, we already have hospitals that are having to give up specialised departments because they lack the necessary staff," says Saxony's head of hospital München. Uwe Köhler, deputy head of the Saxon State Medical Association, reports similar experiences: "A high degree of service consolidation and overbureaucratisation have led to a flight of doctors and nurses." However, State Secretary Neukirch also sees a counter-trend: "The rise in wages has made professions in the healthcare sector more attractive. This is proven by training figures."

What Jan Anastassis Skuras from the Sächischer Hausärzteverband misses in all the discussions about new hospital structures is the role of outpatient care. "Our practices are already overcrowded," says Skuras. And in the coming years, hundreds of doctors in private practice will be retiring. Skuras would like to see cross-sector planning. However, according to the head of the München Hospital Association, this has so far failed mainly due to the old requirements for authorisation and remuneration.

However, all healthcare stakeholders agree on one thing: additional money is needed to organise the necessary restructuring. And quickly. Josef Hecken expects 50 billion euros across Germany. Karl Lauterbach remains silent.

Article in the "Sächsische SZ" from 01 November 2023