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Red Flag

Red Flag: How Karl Lauterbach helped ruin Germany’s hospitals

Neoliberal reforms by 'healthcare economist' Karl Lauterbach have left Germany's nursing industry in crisis.

The neoliberal reforms made by Karl Lauterbach in the early 2000s have left Germany’s healthcare system in crisis. Photo: IMAGO / Political-Moments

Enter a German hospital these days and it can look like a zombie film set on a space station: chock full of incomprehensibly complex machines, but with very few people left to run them. 

The shortage of nurses has reached catastrophic levels. 22,300 positions in hospitals are currently unfilled. Of those remaining, 40 percent are thinking about quitting.

The numbers for Germany’s healthcare system are contradictory. The country has plenty of hospital beds, but a far lower staffing ratio than other wealthy countries. Each bed in the United Kingdom is staffed by 3.1 nurses — in Germany there are 0.8. Or put another way, each nurse in the United States is responsible for 5.3 patients — in Germany they have to deal with 13.

Any nurse can tell you what this means in practice: a single person might be responsible for a station with 20 patients for the entire night shift. What are they supposed to do if two machines start beeping at once? Or if they simply need to go to the bathroom? The answer is banal and terrifying: people die. 

Each nurse in the United States is responsible for 5.3 patients — in Germany they have to deal with 13.

Germany’s premiere weekly, DER SPIEGEL, just published dozens of testimonials from nurses, mostly from Berlin’s public hospitals, each more disturbing than the last. One midwife speaks about trying to take care of seven (!) women giving birth simultaneously. In the end, a newborn falls onto the floor because there is no one around to catch them.

Politicians act like the nursing shortage is some kind of natural phenomenon — like a drought. But it is actually a product of neoliberal reforms to the German healthcare system from the early 2000s. The goal was to make Krankenhäuser more “efficient”. This meant cutting the number-one cost factor: human labour.

Hospital administrators have been endlessly creative in reducing the number of workers. The system is only running because nurses have been willing to do the work of two or more people. But as we’re seeing: fewer and fewer of them are willing to sacrifice their bodies and minds on the altar of “black numbers” and profitability. 

Hospital financing used to be a simple affair: they were reimbursed for the costs of care. Since 2004, however, payments have been made according to DRGs, or Diagnosis Related Groups. When a patient is admitted to hospital, they are assigned a DRG and the hospital gets a fixed sum, regardless of the actual costs. The incentives are thus to get people out as quickly and with as little care as possible.

Let’s look what this means for people with a common problem: knee pain. The most effective treatment is physical therapy, which requires oodles of labour, and therefore cannot generate much profit. A more questionable treatment is surgery, which can be done in an hour by a specialised doctor, and billed accordingly. As a result, the number of these surgeries has grown explosively, at the expense of patients’ outcomes. Doctors report that they are instructed to meet a certain quota of surgeries each month, regardless of what they feel is medically necessary.

Imagine if fire departments were financed like this, getting a fixed amount each time they put out flames. It doesn’t take much imagination to see that within a few months, firefighters would be committing arson in order to keep their profession alive. That is how Germany’s hospitals are run.

Lauterbach has spent his career calling for the closure of hospitals in order to make healthcare “efficient”

The architect of this neoliberal system was a little-known “healthcare economist” who was an advisor to the health minister in the early 2000s: Karl Lauterbach. He has since become Germany’s health minister. In the early days of the pandemic, Lauterbach earned a reputation as an advocate for science. Yet he spent his career calling for the closure of hospitals in order to make healthcare “efficient”: more profitable for the very wealthy, and worse for everyone else.

These reforms initiated a vicious circle: staffing shortages have made it impossible for nurses to do their jobs. So more and more have quit, worsening the shortages and making the profession even worse. They could at least be compensated for their heroic efforts — but their pay is quite low, and many are yet to receive the meagre pandemic bonuses they’ve been promised.

The effects of these neoliberal reforms aren’t limited to hospitals. As this brilliant opinion piece in the New York Times makes clear, privatised healthcare systems erode social trust, and lead to vaccine hesitancy. There was a time from the 1950s to the 1970s when vaccines were almost universally accepted — this was also the time when healthcare systems around the world were becoming universal. When doctors took care of everything for everyone, there was no reason to doubt their recommendation to get a shot. 

Now when I go to the doctor, I can’t avoid the feeling of entering a used-car dealership. Are they recommending this treatment because it’s the best, or in hope of some out-of-pocket perks? In this situation, it’s unavoidable that people don’t trust vaccines. When health minister Lauterbach wonders why more people aren’t getting the shot, he only has his neoliberal ideology to blame. The best recipe against vaccine hesitancy would be to make sure the healthcare system is adequately financed and available to everyone. This could be paid for many times over by making the wealthy pay taxes like everyone else. 

If you follow reporters who cover the workers’ movement, you’ve read about strikes for safe staffing ratios that have been going on since at least 2015. Now, new strikes are set to take place around May 1.

I hate to say it, but if you’re a human being, you will need the services of a hospital sooner or later. It affects us all if nurses are taking care of 20 patients each. So when you see the strikes, remember they are striking for you. 

Want more Red Flag? Here’s Nathaniel Flakin on why public transport should be free

Nathaniel Flakin’s new anticapitalist guide book Revolutionary Berlin is available now from Pluto Press. 304 pages, €18.99 / £14.99.