Read the Conversation
Meeting highlights:
- Hospital Reform: The recently approved reform has faced criticism for being inadequately designed and requiring immediate improvements. Stakeholders, including hospitals and federal states, were largely excluded during the development process.
- Challenges in Implementation: Key aspects of the reform, like the composition of service groups and the new financing for the provision of services, lack clarity, making reliable hospital planning difficult. The introduction of new service groups disrupts established frameworks, such as those in North Rhine-Westphalia.
- Personnel Shortages: Berlin faces significant shortages of healthcare workers, with a projected need for an additional 10,000 full-time nurses by 2030. Efforts to address this include campaigns to attract nurses, better working conditions, and integration of foreign workers.
- Digitalization Efforts: Investments in digital infrastructure are advancing but face challenges like supply bottlenecks and funding for ongoing costs. A notable success is the creation of an electronic patient file platform used by almost 85% of hospital beds in Berlin.
- Primary Care and Efficiency: The shortage of primary care doctors forces patients to rely on emergency services, straining hospital resources. There is a need for greater public health awareness and system competence to optimize resource use and adopt technologies like telemedicine effectively.
EF: Could you give us your reaction to the reform and how will it affect the hospital eco-system?
MS: The Council of Federal States (Bundesrat) approved the reform, which will now be published by the federal president, taking effect in 2025. The version initially passed by the German Bundestag faced strong criticism from stakeholders, including vendors, federal states, hospitals, and health insurance funds, as their concerns were largely ignored. As a result, the federal states and Bundestag members—backed by the former coalition—must now take responsibility for its outcomes starting next year. It is widely acknowledged that this reform is poorly designed and needs significant improvements. Beginning such a long-term reform expected to last at least 10–15 years with flawed legislation is concerning. Politicians should have recognized their responsibility earlier, but they didn’t. Now, ministerial decisions are needed to address gaps. Though slow to act, the federal health minister has a legal basis to issue three key regulations, which must be jointly decided with the federal states. These regulations include expanding the transformation fund, defining service groups for hospital planning, and setting minimum operation thresholds for hospitals.
Last week, the health minister announced that the first regulation regarding the €50 billion transformation fund was ready for co-decision. Starting in 2026, the fund aims to invest €5 billion a year, with the costs split equally between the federal government and the states; however, disagreements over where the money should come from created tension within the coalition. The finance minister refused to use federal funds, so the health minister decided to pull money from health insurance reserves instead. This decision has sparked controversy, as it uses money meant for insured individuals, and this will likely end up in court.
The reform introduces new hospital planning methods using service groups. North Rhine-Westphalia has already piloted this model, using 60 service groups for its hospital plans. The latest reform mandates adding five more service groups to the existing 60. This mandate creates uncertainty about how the new service groups can fit into the existing ones. This adjustment could disrupt the current plans in North Rhine-Westphalia. The criteria and structure of the new service groups still need to be clarified, delaying reliable planning, including in Berlin, where a new procedure has already started.
The reform's structural cost financing plan is another weak point. Experts and studies have repeatedly pointed out that the current plan needs to be revised and is unlikely to work as intended. The new government must revisit these financing issues as elections will be held around February 2025. Even though we are hopeful, hospital funding may not be the most urgent priority the new government will have. Despite its shortcomings, the reform offers a starting point for change. Hospitals support restructuring and streamlining. However, their biggest drive and priority is that the reform needs to be more organized and well-thought-out. The funding issue needs to be well thought out to drive well-managed transformation. Instead, the current structure could lead hospitals toward bankruptcy, leading to unplanned closures. The process needs to be guided by clear and sustainable strategies to improve truly healthcare.
EF: How have you identified the lack of healthcare personnel going into the next fifteen years, and what are you doing about it as the federation to address it?
MS: We already feel the strain of understaffing in Berlin's healthcare system. For instance, only 85% of hospital beds are usable due to a shortage of health workers, a problem expected to worsen. A recent study commissioned for 2030 found that Berlin will require an additional 10,000 full-time nurses to support its expanding and aging population. In response, we launched a campaign in 2020, complete with a dedicated website to address this challenge. We're exploring all options to boost nursing capacity, from improving education and working conditions to integrating foreign nurses and creating more recognition for the profession. We're also encouraging former nurses to return to work and even helping healthcare workers find affordable housing, which is becoming increasingly scarce in Berlin. The issue isn't limited to nurses; doctors, especially in primary care, are also in short supply. Despite being an attractive and growing city, Berlin can't fill all its primary care positions. Patients often wait weeks or months to see specialists, and many end up in hospital emergency departments for acute care.
A reform to improve outpatient and acute care has stalled due to the breach of the coalition, but I'm hopeful the next government will revive these efforts. Even so, these reforms won't fully solve the core problem—there aren't enough doctors in the primary care sector. This issue will require a broader restructuring of the healthcare system, likely well beyond 2025 or 2030. As a nation, we must rethink our reliance on highly specialized care in primary and hospital care settings. We need to take on a more integrated approach that could redistribute responsibilities, especially as younger doctors increasingly prefer salaried, part-time roles without the financial risks of running private practices. This idea may face some resistance, but it is necessary if we are to step forward.
Another challenge lies in educating the public. People need better health literacy—not just to maintain their health and avoid risks but also to navigate the healthcare system effectively. Too many patients visit expensive hospital emergency facilities for issues that could have been managed more affordably in primary care. We can promote telemedicine and primary care hotlines for simpler needs instead of patients heading straight to specialized care. It's not just about reforming institutions but also about empowering people to use the system more efficiently. This will save money and ensure resources are available when truly needed.
EF: How are you investing in new devices and processes to enhance the digitalization of hospitals, and how can you ensure this technological investment is sustainable?
MS: Hospitals showed great effort and adapted to new systems with forms and decision-making processes when applying for a 4,3 billion Euro “future fund.” This fund had been set up in order to lift Germany’s hospitals to the next level of digitalization maturity. But we faced challenges. Bureaucracy worked as expected, but delays and quality issues emerged once 1,700 eligible hospitals began ordering the same products and services from a limited number of providers. As a result, hospitals didn't receive what they initially expected. To deal with this, we've extended the deadline by a year, including holding off on penalties for hospitals that couldn't meet the requirements on time. It was clear we couldn't stick to the original timeline. Despite these challenges, the investment did lead to significant progress. We've seen a real digital boost in hospitals backed by research, but making this progress sustainable is tricky.
Keeping hospitals at this higher digital level is a costly undertaking. There are constant costs for renewing licenses, updating hardware and software, and reinvesting in systems. None of this is currently built into the way hospital funding works. The federal states responsible for hospital investment funding struggle to cover basics like buildings and equipment. Adding digital infrastructure and personnel to their plate is a whole new challenge.
Then, there’s the issue of finding the right people to handle these increasingly complex digital systems. Hospital IT is unlike any other IT; it has to integrate everything from medical devices to doctors and nurses, and it’s incredibly specialized. This requires highly specialized IT staff, but hospitals face tough competition from other industries that offer better pay. We’ve started working with universities to develop specialized study programs to tackle this. The idea is to train the IT professionals we need to manage and grow these systems. If we want this investment to last, we must keep building the right infrastructure and bringing in the right people. It will take a lot of effort, but it’s the only way to make this work long-term. We have to start immediately with the training.
EF: From many of your members from the federation, are there any key success stories, collaborations, or initiatives you have worked on with your members that you would like to share that make Berlin an attractive place for healthcare management?
MS: Regarding digitalization, we're incredibly proud of our progress with some of our largest public hospitals. Charité University Hospital Berlin and Vivantes, Germany's largest community hospital, teamed up to develop a platform for electronic patient records. With this system, doctors at one hospital can securely access a patient's medical history from another—provided the patient consents. It makes sharing important information from past hospital visits across different facilities much easier. Beyond these two major hospitals, we worked closely with the Berlin Hospital Federation to bring many other hospital operators on board. Today, the platform covers nearly 85% of all hospital beds in the city. It's a great example of how sharing knowledge and resources can improve patient care.
EF: Do you have a final message to share with our readers?
MS: I wish we had more time to talk about the challenges of bureaucracy, as it is a real headache. It eats up so much of our time and resources, drives up costs, and takes away from our ability to focus on patient care. That could be a topic for a third edition of your journal next year.
