Care reform under criticism: Experts are calling for structural changes instead of pure financing

Dusseldorf. The nursing reform by Health Minister Carsten Linnemann (CDU) does not go far enough, according to nursing experts. They criticize the fact that the draft only addresses the revenue side and ignores structural problems - and point to approaches abroad.

Last Wednesday, Linnemann brought a draft through the federal cabinet that increases the contribution assessment limit and the childless allowance and contains changes, for example, to rehabilitation. According to him, a commission should work out further reforms.

David Matusiewicz, professor of medical management at the FOM University and expert in digital health, criticizes: "The care reform would have to take a much more structural approach. I lack an overall strategy." In two to three years you will be back where you are today. Significant savings in expenses can be achieved through less bureaucracy, more digitalization and new care models - models that have long been tried and tested elsewhere.

Several countries organize their care fundamentally differently than Germany. However, transferring their systems to Germany is not without hurdles - and at the same time shows the greatest weaknesses of the German system. A look at three countries that Germany could learn from.

The nursing service pays based on the time actually spent instead of based on fixed service complexes. According to an evaluation commissioned by the Dutch Ministry of Health, the amount of care required falls by around a third - with, according to Buurtzorg, 60 percent fewer sick days. Buurtzorg also wants to counteract the shortage of skilled workers in nursing.

Buurtzorg started in Germany for the first time in 2018 - in North Rhine-Westphalia (NRW). A few years later, it had to file for bankruptcy there and at ten other locations. Only Münster and Munich remained. The operators had calculated the price per minute too low and the bureaucratic hurdles were too high. The federal structure in Germany further increased the administrative burden.

In addition to the costs, the lack of training for nurses was also a barrier. “The German healthcare system is very strongly tied to hierarchies,” says Matusiewicz. This goes hand in hand with a clear distribution of roles: nurses primarily take on helper roles, which also shapes their personality. Employees in German nursing are “different in type”. Models like the one in the Netherlands are therefore “not for everyone” and can “seem overwhelming”.

Michael Ewers, director of the Institute for Health and Nursing Science at the Charité, finds even clearer words: “In an international comparison, Germany is at the absolute bottom when it comes to training.” The motto in this country is often “A lot of heart, a lot of hand, little brain”. Buurtzorg works according to the opposite principle: In the Netherlands, around 40 percent of nursing staff are academics.

The Austrian model Time Cushion also focuses on the neighborhood. Volunteers receive a time credit instead of a salary. Every hour worked ends up in a personal time account and can be redeemed later if you need help.

Zeitkissen has been active for eight years - now in seven Austrian federal states and, according to the Association of Private Health Insurance Companies (PKV), in around 20 percent of the municipalities. Around 2,700 volunteers are taking part.

Matusiewicz is a founding member of Zeitkissen Kreis Recklinghausen, which started in the summer. The idea: People should be able to live in their own home for as long as possible. The model complements medical and nursing services and thus helps ensure that older people are not dependent on government services for everyday things.

Many people end up in nursing homes because no one can take care of them in everyday life, not necessarily because they need care, explains Matusiewicz. Time cushion organizes transport services, accompaniment to doctor's appointments, shopping, walks and conversations.

In Germany, the PKV Association is financing a five-year start-up phase with two lighthouse regions, supported by the German Postcode Lottery. However, so far there is hardly any experience in urban areas. “It may be that such a concept does not work in a more anonymous big city,” says Matusiewicz. In any case, there is no one model for everyone - time cushions complement many other, some already existing offers.

Charité Professor Ewers also sees such neighborhood initiatives as an opportunity for German care. Society and politics must prevent those in need of care from ending up in homes and being excluded from society for as long as possible.

Japan, like Germany, relies on long-term care insurance - although it is only mandatory from the age of 40. In order to continue to pay for care, Japan gradually increased the co-payment for higher incomes to 30 percent, the contributions increased, and the state adjusted the eligibility requirements.

This means that Japan faces similar challenges to Germany. However, in Japan, home care is organized more through the neighborhood, whereas in Germany it is often provided by the family. Japanese people have a stronger sense of social responsibility. In Germany, society still relies too much on the state when it comes to care, say both experts.

In addition, care in Japan - in contrast to Germany - is closely linked to medical services, says Ewers. "Unfortunately, we have organized our social security system into pillars. We have to move away from offering all benefits in a fragmented manner." This would result in unnecessary costs and bureaucracy.

Japan is also significantly ahead of Germany technologically, but the use of care robots and other technology cannot be easily transferred, says Matusiewicz. “In Japan, acceptance of care technology is much higher.” Germany is still a long way from using technologies to this extent. But digitalization could also significantly improve care in this country.

Ewers warns against idealizing existing care models. In Tokyo, for example, health care looks very different than in the Japanese countryside. Likewise, NRW and Brandenburg cannot be compared. There is no ideal model.