Feature

After the wall came down

Reunification has proved a mixed blessing for healthcare in Germany, reports Uli Freudenstein

Many workers in the primary care sector of the NHS feel overwhelmed by the pace of change over the last two years. They might feel better if they compare their fate with that of their East German counterparts.

East and West Germany were reunited in October 1990. The borders opened in 1989. There was little time for planning change. The East Germans had to face a virtually complete changeover from their own political, economic and medical care system to that of West Germany.

In the East, primary care had been provided from health centres staffed by 1-50 doctors/dentists (not including all other staff). The larger health centres staffed smaller satellites and were often attached to the district hospitals. All staff were salaried. Medical staff consisted of general practitioners and specialists. Access to the latter was direct or by referral from GPs. Medical care was free. A private sector did not exist but there were medical facilities catering for politicians and administrators. Problems lay in very limited local budgetary flexibility, drug supply failing to cope with peak demand and low availability of expensive medical technology. The district nursing service was comprehensive and similar to the UK model. An occupational health service carried out surveillance for all workers and also undertook the primary care of workers and relatives where convenient.

Prior to reunification, lobbying by the West German Medical Association (Bundesaerztekammer) took place with the aim of virtually outlawing a salaried service based in health centres. Its aim was to introduce the West German model of the GP or specialist working as an independent contractor paid on an item of service basis. They would employ other staff or refer on to similarly independent physiotherapists and so on.

Health centre staff are now to remain salaried until 1995. But after that no solution exists and they can only continue in existence if they are taken over as a whole centre by one financing body.

Previously health care in East Germany was financed by national insurance and tax contributions. This has been replaced by a complex system of 1200 insurance bodies (mostly non-profit making) whose money comes from the insured, their employers and the staff if the insured person is receiving state benefits. The occupational health service will be confined to surveillance tasks.

Faced with an uncertain future, doctors set themselves up in practice. One year after reunification, 50 per cent of doctors were said to be independent contracts. Now, 20 months after reunification, apparently more than 80 per cent of all primary care activity is delivered by independent contractors. All doctors, whether employees or independent contractors, have to deliver detailed returns for the item of service system.

One might argue that the transition to the Western model was the only workable option under the circumstances. Patients benefit from better access to drugs and medical technology (which unification with the richer neighbour would have brought anyway). But their insurance contributions now have to finance the production of items of service for income generation and many more and many unnecessary pharmaceutical products. Patients also have to pay prescription charges and contribute to the cost of some drugs as well as some dental treatment. The transfer of the much criticised insurance system with its large and effectively unnecessary administration will hardly help.

Health service employees have to work harder nowadays if they have not already been made redundant. Older doctors and those suffering ill health will be unable to become independent contractors as no bank will lend then the necessary money.

A good system of training for general practice has been abolished and replaced by a poorly organised system in dire need of reform.

These doctors least affected are those in rural areas and those who became independent contractors early on when rents were cheapest. The others face an uphill struggle for premises and patients. To date all earn 60 per cent of the income of their Western colleagues. Nurses can presently head for better paid jobs in the under-supplied West but other staff are not so fortunate.

The changes have been extreme. The argument that the item of service system is more cost effective is at best unproven. Health service staff and doctors may well have to work harder for their hard currency and have lost many social benefits. That this should be the price for increased political freedom does not follow. But that it has been a success for the German Medical Association’s astute lobbying can not be doubted. Its aim, to avoid any comparable salaried sector, has been achieved.