Germany showcases efforts to maintain healthcare system in light of declining and ageing populations
Newsletter 2009-3
Publication date : 2009-11-25
A
shortage of physicians in the Land
of Brandenburg, due to
the region’s particularly sparse and ageing population, triggered the June 2009
Potsdam
meeting, where policymakers from some EU countries gathered to discuss how best
to maintain the supply of healthcare services to local populations. To
address its healthcare problem, the Land
of Brandenburg has
introduced a number of measures, which it wished to share and debate with other
Member States – the challenge of ageing being common to many parts of the EU. Measures
taken included the introduction of financial incentives for doctors taking over
practices in underserved regions, the provision of fellowships and additional trainings
for medical students and doctors, the launch of a pilot project to support
immigrant doctors, and support for research into telemedicine. Another
key initiative was the so-called AGnES project, which aimed to ease doctors’ workloads
by enabling the delegation of certain medical services to qualified community
nurses, who could conduct at-home visits to patients in rural areas with
scattered populations. Nurses carried out standard state-of-health checks, such
as blood pressure measurements, blood samples, injections and ordering
prescriptions, most often for patients with restricted or no mobility. This
pilot project, which took place from July 2006 to December 2008, relied on new information
systems to ensure a close connection and mutual feed-back between the general
practitioner (GP) and the nurse, namely for medication requests and hospital
admissions, for which doctors must legally be consulted. The
results of the project were positive, with a strong degree (over 90%) of
acceptance for the concept of community medicine nursing among participating
GPs, nurses and patients. Despite
this success, Peer Review participants had differing views on the legitimacy and
benefits of letting nurses take over doctors’ responsibilities. While some felt
that nurses can quite adequately perform many of their tasks, citing literature
demonstrating that 50-80% of what primary care physicians do can be done
equally well and more cheaply by a nurse1, others pointed out that nurses undergo
different and shorter training than doctors and are therefore less qualified to
make diagnostic decisions. Discussions
highlighted the sensitivity of substituting physicians with nurses, as this
could in many health care systems threaten the income and employment of medical
practitioners and be vigorously opposed by their professional associations. Opposition
to nurse substitution would likely be strongest in countries where physicians are
funded through fees per service – which is namely the case in for instance Germany, while countries where physicians are
remunerated by salary and by capitation, e.g. Ireland,
the UK, Nordic countries and
the Netherlands,
could face lesser difficulties. Nevertheless,
such resistance is likely the reason why, despite existing evidence, no country
has ever explicitly declared its intention to reduce the physician stock and
replace doctors with trained nurses, and why the German scheme remained limited
both in scope and geographically. Indeed, the Brandenburg project remained under a high
degree of physician control, which, based on stated evidence, would be
unnecessary if efficient provision of care for the trial population were the primary
goal. The
meeting in Potsdam
thus demonstrated a gap between the existing research evidence base and policy design
and implementation in healthcare. Future policymaking will have to invest further
in this area and reflect on how to better translate the existing evidence base
into concrete policies. This could require a turnaround in the use of financial
and non-financial incentives that form the basis of the existing health and
social care delivery systems, and that sometimes have perverse effects in terms
of providing high quality care to citizens and motivating funders to be more
efficient. However,
a gradualist approach, with a strong emphasis on quality evaluation, productivity,
and providing better healthcare for patients, will be necessary since, in fine,
all reforms are also experiments on patients. 1 Laurant, MGH; Reevers, D;
Hermens, R; Braspenning, J; Grol, R; and Sibbald, B: Substitution of doctors for
nurses in primary care (review) John Wiley and Sons Ltd, 2005, Cochrane Library
issue 5.
