For years, politicians and health economists in Germany have complained that the country has too many hospitals. The coronavirus pandemic has turned this oversupply into an asset.
At the outset of the pandemic, Germany had 28,000 intensive care beds, more than most of its neighbouring countries. In recent days that has been raised to 40,000, as hospitals brace themselves for a huge influx of patients with Covid-19.
“In contrast to Spain, France and Italy, we have a very high density of hospitals and beds, and this has emerged as a big advantage in this crisis,” said Uwe Janssens, head of the German Interdisciplinary Association of Intensive Care and Emergency Medicine (DIVI).
“The irony is, it’s something we were always criticised for in the past.”
Indeed, an influential study by the Bertelsmann Foundation last year recommended that the number of hospitals in Germany should be more than halved, from nearly 1,400 currently to fewer than 600. Only such a radical consolidation would “improve patient care and mitigate the shortage of doctors and nursing staff”, the study’s authors wrote.
“I’m pretty sure that we’re now going to see a different approach to this debate and the arguments that were being made before the corona crisis,” said Gerard Gaß, head of the German Hospital Federation (DKG). “That’s been one of the lessons of the pandemic.”
Germany has more than twice as many vacant critical care beds as England has in its system overall. It is running as many as 100,000 coronavirus tests a day, many more than its neighbours. It has significantly increased its supply of ventilators, ordering 10,000 in mid-March to add to its existing 20,000 machines.
The widespread use of testing from the epidemic’s early stages, which covered all those with mild symptoms, allowed authorities to quarantine infected people and isolate and monitor all those they came into contact with. It has also been cited as one of the reasons why the number of deaths in Germany is so low. By Saturday, there were 122,171 coronavirus infections in Germany, but only 2,736 Germans have died of Covid-19. That means the proportion of people who have died after a corona diagnosis is just 2 per cent, compared with 13 per cent in Italy and 10 per cent in Spain.
But medical experts say another key factor is the number of hospitals in Germany. The country boasts a total of 497,000 hospital beds for general and acute care: by contrast, the UK has 101,255, 44 per cent fewer than it had in 1988. All three tiers of the German system — the big “maximum-care” and general care hospitals and the smaller, primary care facilities — have been treating Covid-19 patients, since even smaller institutions have intensive care units (ICUs).
“The fact that our capacities are widely distributed over such a large area has been extremely helpful and it’s one of the reasons why the situation in Germany is relatively relaxed,” said Dr Gaß.
A recent survey by the OECD found that before the crisis Germany had 33.9 intensive care beds per 100,000 people, compared to 9.7 in Spain and 8.6 in Italy. Figures from the German federal office of statistics from 2017 show that 14 per cent of all ICU beds in Germany are in the 840 small hospitals with fewer than 200 beds — the category that Bertelsmann said should be shut down.
Italy has worked hard to increase the number of intensive care beds in its hospitals, from 5,223 before the pandemic began to 6,634 from last Wednesday, according to data provided by the ISPI think-tank. Madrid and Catalonia, the two Spanish regions hardest hit, have more than tripled their intensive care beds by Wednesday— to 1,893 in the case of Madrid and 2,010 in Catalonia.
But the increase in Germany is on a much bigger scale. It happened after the government in Berlin last month directed hospitals to postpone all routine procedures and elective surgery and at the same time promised them generous compensation for any lost income. They will receive €560 a day for every bed they keep vacant for a potential Covid-19 patient, and €50,000 for each additional intensive care bed they create. Since then, occupancy rates in German ICUs have been pushed down from 75-80 to 50 per cent and the number of beds available has shot up.
Germany’s high number of beds has a lot to do with the way hospitals are reimbursed by patients’ health insurance funds, the so-called Krankenkassen, for the treatments they carry out. “The system is very geared towards inpatient procedures like operations,” said Ricarda Milstein of the Hamburg Centre for Health Economics. “Hospitals have a financial incentive to provide as much inpatient care as possible.”
That leads to comparatively short waiting times. “But the disadvantage is that we have a really big oversupply,” said Ms Milstein. “We have a hotchpotch of many small hospitals, some of which don’t meet the required quality standards.” Some institutions do not have enough staff and equipment, and “quality problems can lead to higher mortality rates”.
Indeed, OECD data show that Germany does not score particularly well when it comes to staffing levels. It has 2.4 hospital doctors per 1,000 people, compared to 2.6 in France and 3.2 in Switzerland, and only 5.6 qualified nurses per 1,000 people, way behind Norway with 9.1.
Inadequate staffing was one of the issues identified by the Bertelsmann report. It said many hospitals in Germany lack the necessary equipment and experience to treat life-threatening emergencies such as heart attacks or strokes. Only by consolidating the system can complications and deaths be avoided, the study said.
Some experts say Germany should emulate Denmark, which has over the years merged specialised functions into fewer and larger hospitals. “But that will mean a reduction in beds,” said Mr Janssens. “And then what happens when we have corona 3 or 4? Then we’ll have the same problem as our neighbours.”
Additional reporting by Daniel Dombey in Madrid and Davide Ghiglione in Rome
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