"When it comes to the shortage of skilled labour, we have entered a vicious circle"

Wuppertal economist Vera Winter on problems in the healthcare sector

"Germany's clinics are running out of staff" was the headline on Deutschlandfunk radio. Working between excessive demands and resignation, many employees are pulling the ripcord. Prof. Dr Vera Winter, economist at the Schumpeter School of Business and Econmics at the University of Wuppertal, analyses the work situation of staff in hospitals and inpatient care facilities at her Chair of Management in Healthcare and says: "The shortage of skilled workers is a major issue. We have entered a vicious circle." The problem has been developing since 2003, when the red-green government under Health Minister Ulla Schmidt introduced so-called flat rates per case. Hospitals began to reduce staff costs; as a result, fewer staff were available and the remaining nursing staff were often overworked, were absent more often due to sick leave or even changed careers. Although politicians recognised the dilemma after a few years and took countermeasures, they have not yet been able to break this vicious circle. With the sheer number of nursing staff, Germany is not in such a bad position, explains Winter, "but we have the historically grown problem that we have too many facilities where the nursing staff is spread out. The overprovision that we see in the hospital landscape also means that there are too many facilities to care for." There is now a rethink in hospitals, new working time models and a break-up of hierarchical structures, but this is very difficult to implement. "There are steps in the right direction, but something has to happen quickly!"

Flat rate per case system - a good idea from an economic point of view

The DRG flat rate system (DRG stands for "Diagnosis Related Groups", a classification system for a flat-rate billing procedure, editor's note) can be explained in simple terms as follows: For patient X with diagnosis Y, a hospital is paid amount Z by the health insurance company, regardless of how long the person stays in the hospital. Perhaps no longer up to date today, professional management's hands seem to be tied at this point. "Hospital financing is a complex issue," begins the expert, "DRGs were introduced back then because costs kept rising, because hospitals could do anything and therefore be uneconomical. They were more or less reimbursed for all costs, which meant that there were no incentives to be economical. Economical does not always mean saving on quality, but also means, for example, avoiding duplicate examinations or simply not operating on indications where it is not necessary. That was the reason for introducing this system, and in my opinion it's a good idea!" However, the development of the system has shown that it has also created false incentives and, for example, encouraged an increase in the number of cases. In addition, general inpatient care is much more attractive than outpatient operations at hospitals because the latter are largely remunerated at a much lower rate. "These false incentives that came from the DRG system got out of hand at some point. The number of cases has continued to rise, which cannot be explained solely by changes in the burden of disease in the population. And hospital expenditure has not been curbed as a result," explains Winter.
Scientists are of course thinking about alternatives, but what costs are justified? And what is the best way to control them? Winter comments: "This is a huge debate, without an optimal solution. Something substantially new is being launched right now and it will be exciting to see whether it achieves the desired goals or whether we create new disincentives."

Supply is complex and difficult

A report recently came from Berlin: 80 per cent of doctors at the Charité in Berlin gave the quality of care at the hospital a grade of four or worse. "Care is incredibly complex and difficult," explains the scientist. Large hospitals with a diverse range of treatments often have difficulties ensuring quality in all areas. What's more, the shortage of specialised staff not only affects nursing staff, but also doctors. "University hospitals are also affected by above-average costs in the DRG system, because they don't have all the minor cases in their area, but rather the more serious cases, which means they can never keep up with the costs. The other thing is that you always know what would potentially be possible but is not feasible in the system."

Digitalisation in the healthcare sector - a German problem?

The digitalisation process in the healthcare sector is not seen as a relief. Health Minister Karl Lauterbach even stated: "In terms of digitalisation, we are a developing country compared to the rest of Europe." Has Germany been asleep for years? "We could ask the universities the same question," laughs the scientist. "I worked in Denmark for a few years and the status of hospitals and universities there is completely different. Digitalisation is generally a German problem. In hospitals, the fact that operating costs are only ever financed at what is effectively the average price makes it difficult to implement new digital solutions, because where do you get the money from?" Officially, investments should be channelled through the federal states, but there is also a huge investment backlog to consider. "It's very difficult for small centres to implement something. And if they do, it often runs parallel to the old processes. We have a lot of different digital solutions that are not linked to each other, so it's double the effort."

Case documentation - both a blessing and a curse

On average, nursing staff spend around three hours a day documenting cases. In the case of doctors, a third of their colleagues spend more than four hours documenting cases. The German Hospital Federation once calculated this: If we were to reduce the three hours of nursing documentation by just one hour, it would free up the working time of 60,000 full-time nursing staff. "This is an incredibly difficult field," says Winter, "because we also need the data." If, for example, a patient's medication is not documented (preferably digitally), it is not possible to ensure that the carer on the next shift administers the same dose again. "This is the only way we can ensure that researchers also have access to this data and can see whether, for example, the administration of medication is in line with guidelines or whether combinations of medications that must not be administered together are taken into account."

Similarly, the lower limits for nursing staff, for example, are documented today to show that only the maximum permitted number of patients are cared for per nurse in order to really guarantee the quality of care. However, there is now such a large number of quality assurance measures, which is also perceived as excessive control bureaucracy in the hospitals. This raises the question for Winter: "So how do we get to the point where we trust hospitals to manage this intrinsically?"

The German language is a major hurdle for foreign specialised nursing staff

According to the Gesellschaft für Qualitätsmanagement in der Gesundheitsversorgung e. V. (GQMG), the actual language skills of foreign nursing staff in Germany vary greatly. After arriving in Germany, the immigrant nurses are usually immediately confronted with the complex tasks of German specialised nursing care in nursing facilities due to the shortage of skilled workers. In the analysis of the integration of nursing staff with a migration background, Winter confirms that language is one of the biggest hurdles, although some facilities have recognised this. "Integration will only succeed if we invest in it properly. Language courses need to be financed in advance and integration managers need to be in place to support the nursing staff. The homes that can do this tend to be more flexible when it comes to integration." In contrast, less solvent hospitals that cannot afford this service, but are also dependent on foreign employees due to the shortage of skilled labour, would be more likely to tolerate the language barrier in case of doubt instead of not being able to care for patients. "It's a very difficult trade-off," says Winter, "on the one hand, many places can no longer do without nursing staff recruited from abroad. On the other hand, native-born nurses are also frustrated if they can't communicate or if they can't work together. This makes the nursing profession even less attractive."

The role of nursing staff in other countries

Almost a quarter of all healthcare workers have a migrant background. The most important countries of origin are Poland, Turkey, Russia and Kazakhstan. An above-average number of doctors come from Eastern Europe and the Near and Middle East. More and more qualified nursing staff with accreditation are coming through care agencies, but they are not allowed to do everything that qualified specialists are allowed to do. "We can't fully utilise the potential of nursing staff," says Winter, "this is problematic both for those who have to do more and, of course, for the nursing staff themselves, who are suddenly no longer allowed to do their familiar work and become frustrated because they are under-challenged professionally." The specialist calls for better regulation of recognition procedures by the state. There is also a need to look at the scope of duties of carers in their country of origin, as some activities are not part of the standard of care there. "In Germany, nursing staff are also responsible for patient care and positioning, they often help with toileting and serve meals, whereas in other countries, this is done by family members. There also needs to be an adaptation process to teach foreign nursing staff the German standard."

Turbulent changes in management

In a hospital in Wuppertal, there have been five changes of managing director in just a few years, who have always brought in new ideas without talking to the base, i.e. the nursing staff. Among other things, the pharmacy was outsourced and the food now comes from around 50 kilometres away from the hospital. Spontaneous changes to medication or food orders have become impossible. "We are conducting research into management changes, which are much more frequent in hospitals than in other industries. We can also see that this is a very turbulent industry and that management changes naturally produce a lot of change," explains Winter. Every business administration student knows that decision-making processes should never just be top-down, but always bottom-up, and that some decisions can be made undemocratically. "If I can save, say, 50% of the costs of food delivery by outsourcing it and don't have to save the saved 50% elsewhere, then that can make a lot of economic sense. But this also needs to be communicated so that all employees understand it. We actually have three languages in the hospital. We have this medical/nursing language, the medical language and the business language. These are also different ways of thinking, and that's where a lot of things often fail."

Work-life balance instead of willingness to sacrifice

Work-life balance is playing an increasingly important role for young employees. Many no longer want to work full-time. The expectations of young employees are very high, while older employees are often no longer interested in Generation XYZ. Attitudes towards the profession have changed and service offerings such as parent services, where nursing staff are allowed to take their children to nursery before starting work, mean that other employees have to provide additional basic care in the morning for the missing colleagues. This poses major problems for hospitals. "Yes," says the researcher, "you hear a lot of grumbling about the new generation, and I can understand that. But on the other hand, you can ask whether this 'sacrifice' that was expected of the older generations is really healthy? Or is what the new employees are doing not much healthier? At the moment, we are experiencing this generational change and it is at the expense of those willing to sacrifice. But if you no longer have them, but only the employees you really have to look after because there is no one else left, we might be able to achieve a healthier working environment. Parent-friendly working hours should actually be a matter of course, because children have to be taken into account in our society. If we want women and parents to work in general, we need to practise work-life balance. Denmark is much further ahead in this respect, including in the hospital sector."

Uwe Blass

Prof Dr Vera Winter has held the Chair of Business Administration, in particular Management in Healthcare, at the University of Wuppertal since 2019. She previously worked at the Universities of Southern Denmark, Hamburg and Mannheim and completed a visiting fellowship at Harvard University.