4.2 Human resources
4.2.1 Health workforce trends
Health care is an important employment sector in Germany, with 4.9 million residents working in the health sector, accounting for 11.2% of total employment at the end of 2011. Between 2000 and 2011, the number of people working in the health sector increased by a total of 600 000, or 14.6%. Of the 4.9 million residents working in the health care sector, 3.3 million were in health care, 244 000 were in health industries and 1.4 million in other professions such as cleaning and kitchen staff in hospitals. A total of 2.0 million worked in inpatient care or day care and 2.2 million in ambulatory care. Another 0.04 million worked in health protection, 0.06 million in emergency services, 0.19 million in other facilities, and 0.2 million in administration (Statistisches Bundesamt, 2013b).
Between 2000 and 2011, additional jobs were created, in particular in health services and social occupations: the number of physiotherapists increased by 106%, and the number of elderly caregivers by 83%. When broken down according to facilities, the increase in the number of jobs took place primarily in the area of ambulatory care, especially in non-physician practices (+171 000, or +75%), ambulatory nursing care facilities (+104 000, or +56%) and physician practices (+84 000, or 14%) (Statistisches Bundesamt, 2013b). Of the 4.9 million residents working in the health care sector, 68% worked full-time and 32% worked part-time, which corresponds to 3.7 million full-time equivalents (Statistisches Bundesamt, 2013b).
In 2011, the workforce in general and psychiatric hospitals amounted to 1.1 million (another 170 000 worked in inpatient institutions for prevention and rehabilitation and another 661 000 in inpatient care and day-care clinics) (Statistisches Bundesamt, 2013b). The number working in the inpatient sector has increased steadily since the 1990s although the structure of employment shifted during this period. While maintenance and technical employees decreased as a result of outsourcing, the number of physicians, nurses and personnel in medical technical service increased. Table4.5 outlines trends in human resources and graduates in different professions since 1991 according to WHO data.
Over the past 50 years, the number of physicians has increased steadily. The average annual increase was 3% in the 1980s and 2% in the 1990s. Since 2000, there has been an average decrease of 1%. In 2012, however, the number of physicians increased 2.1% compared with the previous year (Bundesärztekammer, 2014).
Of a total of 459 021 physicians in 2012, 348 695 were active. Of all active physicians, 174 829 practised in hospitals, 144 058 in ambulatory care (about 123 000 as SHI-accredited physicians, about 21 000 as employed physicians in SHI physician practices). Another 29 808 physicians worked in the public health care sector, administration, government or other sectors (e.g. pharmaceutical industry) (Bundesärztekammer, 2014). According to WHO data, which exclude the latter two groups, 382 physicians per 100 000 were practising in 2011 (WHO Regional Office for Europe, 2013; Table4.5). The density of physicians was slightly above the EU15 average and substantially higher than the EU13 average, but below the averages in Austria and Switzerland (Fig4.2).
Whereas the number of physicians in general has increased continuously in recent years, the number of qualified GPs has decreased, both in relation to the population and especially in relation to all physicians. However, since an increasing number of internists and paediatricians followed incentives to focus on practising primary care, the ratio of “family physicians” to practice-based specialists is currently 1 to 1.
The number of dentists per 100 000 population has increased steadily since the late 1990s, reaching 80 in 2011 according to WHO. This is higher than average compared with other EU countries (Fig4.3).
The number of nurses has also increased substantially, especially during the 1990s, when long-term care insurance was introduced and provided more jobs in ambulatory care (see section 5.8). From 2000 until 2012, the number of registered nurses and midwives together increased from 718 000 to 826 000. When part-time work is taken into account, nurses accounted for 590 000 full-time equivalents (Statistisches Bundesamt, 2013b). According to WHO data, the number of nurses (11.5 per 1000) in 2011 ranked above the EU28 average (8.4 per 1000), but far below the average of Switzerland (17.4 per 1000) (Fig4.4).
Fig4.5 compares the number of physicians and nurses per 1000 inhabitants in the EU. It becomes clear that the numbers of physicians and nurses in the EU13 (with 2.7 physicians and 6.2 nurses per 1000 inhabitants) are far below the average for the EU15 (3.7 and 8.6). The Nordic countries Iceland, Denmark, and Norway have the largest number of physicians and nurses per 1000 inhabitants alongside Monaco (6.6 and 16.1, respectively) and Switzerland (3.9 and 17.4, respectively). Germany with 3.8 physicians and 11.5 nurses per 1000 inhabitants is ranked number seven in western Europe.
4.2.2 Professional mobility of health workers
As a result of the EU enlargements in 2004 and 2007, growing migration of health professionals to Germany had been expected. In fact, the number of foreign health workers has grown constantly since 2000 and reached its peak in 2003, therefore before the enlargements. The extent of migration to Germany is relatively small compared with that to other destination countries in the EU. Microcensus data from the Federal Statistical Office show that in 2008 the share of foreign health professionals among all health professionals working in Germany was 6%. Of these foreign health professionals, about 15% were born in Germany and around 57% had been trained in Germany as well (Ognyanova & Busse, 2011).
In 2012, the Federal Chamber of Physicians registered 32 548 foreign doctors, that is a 14.8% increase over the previous year. Of these, 18 254 (56%) came from EU Member States, 5616 (17%) from other European countries, 1586 (5%) from Africa, 5886 (18%) from Asia, 337 (1%) from North America, 597 (2%) from Central and South America, and 27 (0.1%) from Australia (Bundesärztekammer, 2014). The majority of foreign doctors worked in hospital (69%), with only 11% working in ambulatory care. The reason for this imbalance might be the higher investment costs for practice-based physicians and the strict legal framework (Ognyanova & Busse, 2011). Reliable data on the number of German physicians working outside the country are hard to find. However, it can be assumed that the outflow of doctors has increased since 2000. Approximately 1% of all active medical doctors left Germany in 2008 to work abroad. The most popular destination countries were Switzerland, Austria, the United States, the United Kingdom and Sweden. Reasons for leaving Germany are poor working conditions and payment (Ognyanova & Busse, 2011).
Since nurses are less strongly organized than physicians in Germany, there is no institution monitoring the number of nurses and their professional qualifications. According to the Federal Employment Agency, a total of 24 387 foreign-national nurses and midwives subject to social contributions were registered in 2008. This is a decrease of 7.5% compared with the total number of foreign nurses in 2003 (26 364). Despite EU enlargement, this effect can also be observed when looking at EU Member States. The number of nurses and midwives coming from EU Member States to Germany decreased from 10 259 in 2003 to 9 971 in 2008 (2.8% decrease). In 2008, 11 013 nurses came from other European countries, 690 from Africa, 560 from America, 2103 from Asia and 50 from Australia (Ognyanova & Busse, 2011). Similar to the physicians, the data available on the outflow of nurses are very poor. The German Nurses Association estimates that not more than 1000 German nurses leave the country each year (Zander, Blümel & Busse, 2013). An EU workforce study on professional mobility in the EU (PROmeTHEUS) found that reasons nurses gave for leaving Germany were high workloads in poor working conditions, limited decision-making powers, a lack of recognition, low remuneration, missing collaboration between nurses and physicians, and poor advanced training opportunities. Switzerland, Scandinavian countries, the Netherlands, Austria and the United Kingdom were identified as major destination countries (Ognyanova & Busse, 2011).
4.2.3 Training of health workers
The training of health care professionals is a shared responsibility of the federal government, Länder governments and professional associations. Most current debates arise out of the tension between the various stakeholders. According to the federal structure, the 16 Länder are generally responsible for regulating and financing education as well as for registering and supervising professions, including health professions. However, health professions have differed traditionally from other professions because of the national regulations for their primary education and the virtual autonomy of the bodies regulating their specializations (secondary professional education) and continuing education. National standards for curricula and examinations were introduced in 1871 for medical studies, in 1875 for faculties of pharmacy and in 1907 for nurse training. Currently, uniform curricular frameworks defined by federal law exist for 17 of 23 non-academic health care professions, for example nursing, paediatric nursing, assistant nursing, midwifery, physiotherapy, speech therapy, technical assistance or emergency and rescue care. National legislation was also introduced to harmonize the primary education of carers for the elderly in 2002.
Primary professional education and registration
Primary training of non-academic and academic professionals is basically free of charge in Germany. However, private schools with course-based training for therapeutic professions demand fees. Participants of practice-based training in health care institutions, such as nurses in training, receive a basic income. University education is financed by the Land and, in some cases (depending on the Land), also through tuition fees, while practice-based training at hospitals has basically been funded by sickness funds since 2000 as part of their financial contracts with individual hospitals. The responsibility for financing nursing schools used to be the state government’s but was shifted largely to sickness funds in 2000. It is funded through an “apprenticeship surcharge”.
Many German universities offer degrees in medicine, dentistry and/or pharmacy. There are also many publicly financed facilities for the primary training of nurses and child nurses, elderly carers, who are trained on the job with additional blocks or days for course-based learning. At the same time, schools for physiotherapists, masseurs, midwives, dieticians and speech and language therapists are often private and require fees (approximately €300 to €700 per month). Primary training of most non-academic health professionals requires an advanced degree after secondary school and usually takes three years.
Access to German universities is usually limited to people with 12 or 13 years of schooling (equivalent to A-levels in the United Kingdom). Academic health education is among the disciplines for which places are distributed centrally according to academic records, waiting times and special quotas (e.g. foreigners or the disabled) although 15% of medical students are accepted by means of interviews at universities. University studies last between four (pharmacy) and six (medicine) years.
The curricula of the university-based programmes in medicine, dentistry and pharmacy differ from other study programmes, organized around two to four centralized examinations as defined by federal law. In 1999, a clause was integrated into the federal ordinance for medical studies allowing individual medical faculties to offer curricula reform while preserving basic federal standards, such as two centralized final examinations. The first reformed medical curriculum started as a second track at Berlin Humboldt University in 1999 with 63 students. In autumn 2003, the ordinance was completely changed with the aim of facilitating profound innovations in favour of bedside teaching, community-based teaching, problem-solving skills and the integration of basic science and clinical subjects.
Since the beginning of the 1980s, cost considerations have motivated health policy-makers to try to reduce university places for health care studies. While educators have not generally agreed, the “detour” via improved lecturer–student ratios was chosen – politically promoted as an improvement of training quality. Since the early 1990s, the number of graduates in medicine, dentistry and pharmacy decreased accordingly, a situation which again led to concerns after the mid-2000s (Table4.5 and Table4.6).
After graduation, health care professionals are eligible for registration at the Länder ministries responsible for health. A regulation that medical graduates receive full state recognition only after having worked in clinical practice for 18 months was abolished in 2004 (see section 3.7.2).
Reforms of training for elderly carers (2001) and for nurses (2003) modernized curricula and enhanced elements of preventive and psychosocial care and community-based practice. Despite initiatives to unify the nursing professions, the traditional profound dichotomy between them has been preserved by the recent reforms of primary professional training. The primary training for elderly carers was harmonized for the first time at the federal level in 2001. The traditionally strong emphasis on social work has been complemented by more training in nursing skills. However, experience in geriatric–psychiatric nursing has still not become an obligatory part of training for those caring for the elderly.
Physician assistants and dental assistants continue to be trained separately in a vocational type of training based at physicians’ practices. Their training was recently broadened by introducing obligatory rotation and modernized to account for changes in patient information, practice management and information technologies.
Secondary professional training (specialization) and continued education
Specialization usually takes two or three years in non-academic health care professions and four to six years in academic professions. Medical and veterinary graduates are obliged to specialize if they want to work as SHI-accredited physicians in private practice, while specialization is optional for the other health care professions. The different Länder in Germany recognize a maximum of 8 specialties in pharmacy, 3 in dentistry, 48 in veterinary medicine, 7 in psychology and 12 in nursing.
The number of medical specialties increased from 14 in 1924 to 37 in 2008, supplemented by another 52 subspecialties or additional qualifications. Based on decisions of an assembly of physician representatives from the assemblies of the regional associations of SHI physicians, the Federal Chamber of Physicians issues a model advanced training regime that is further detailed by the state-level chambers of physicians. For each of these qualifications, a minimum length of training as well as a catalogue of procedures and skills is detailed in the training regime. Subsequent to the advanced training period, physicians must pass an examination administered by specialists in the target qualification.
The duration of specialization in general medicine was increased from three to five years in 1997 in order to strengthen the quality and professional status of future family practitioners. However, GPs amounted to only about 20% of the physicians receiving their specialty diplomas from physicians’ chambers during the 1990s. The low generalist to specialist ratio has been interpreted as reflecting lower income prospects (see section 3.7.2) but also a lack of training facilities in ambulatory care and lower prestige because of the social view of medical doctors in secondary and tertiary hospital care. Therefore, since 1999, sickness funds, private health insurers and regional associations of SHI physicians have been legally obliged to finance half of the GP trainees’ salaries during the office-based training period (minimum two, maximum three of the total five years). However, in practice, the subsidy often is the trainee’s only income, which may explain why, in 2008, of the 11 631 physicians obtaining a specialist degree, only 7.7% were GPs while specialist internists were the largest group (15.3%), followed by paediatricians (5.1%) (Bundesärztekammer, 2009).
A high dropout rate in non-academic professional training and practice has been interpreted as reflecting the employment situation for women, the relatively low job satisfaction in hierarchical systems and the limited prospects for professional development and social mobility. The shortage of nurses was another factor motivating the introduction of course-based specialization facilities at universities of applied sciences during the 1980s. In recent years, nursing sciences have also been offered by public and private universities. Part-time or full-time courses are increasingly offered for other nonmedical professions as well (e.g. physiotherapists, speech and language therapists or carers for the elderly). Polytechnics and private institutions also offer a variety of courses in areas such as health promotion and hospital management. Since 2010, a new “Health University of Applied Sciences” (Hochschule für Gesundheit) has been offering undergraduate courses in occupational therapy, midwifery, speech and language therapy, nursing and physiotherapy.
Public health was an exclusively medical specialty until 1989, when postgraduate courses were gradually introduced at universities, predominantly in medical faculties. The two-year part-time courses are partly free of charge and partly require tuition fees. Quality management is another part-time qualification that has been introduced in recent years at five physicians’ chambers, private institutions and some polytechnics.
Professional chambers of physicians, psychologists, dentists and pharmacists are responsible for regulating, promoting and supervising the continuing education of their members. Since 2004, continuing education has been made obligatory for all health care professionals active in ambulatory care for SHI-covered people. Evidence of appropriate professional development has to be presented every five years. In the case of SHI-affiliated physicians, lack of adequate evidence may lead to a reduction of reimbursement.
The training for hospital nurses, pediatric nurses, and nurses for the elderly will be integrated by a new nursing profession law that was adpopted in July 2017. The law will combine the three existing vocational nursing programs into one standardized two year program, with nurses able to choose whether they will continue to additional general education or specialize in elderly or pediatric nursing. The act aims to reform nursing education in order to standardize the profession of nursing in Germany, and prepare nurses for transferring between positions or for promotional opportunities.
The law is also meant to attract more nurses to the field of elderly care by abolishing the school fee for geriatric nursing school. The first year of THE new training PROGRAM will start on 1 January 2020 to give nursing schools adequate time to prepare for the changes.
Federal Ministry of Health: https://www.bundesgesundheitsministerium.de/themen/pflege/pflegeberufegesetz.html
In October 2015, the German government set up an expert commission to assess hospital nursing staff capacity. By the end of 2017, the commission will report to what extent an increasing care need of patients with dementia and the handicapped as well as the general need for care in hospitals are adequately compensated in the DRG payment system. Already, the federal government has agreed on measures to improve staffing levels in hospital nursing care by a cabinet decision. In hospital units where nursing staff is particularly needed to guarantee patient safety (e.g. intensive care units or night services), minimum numbers of nursing staff will be defined. The minimum limits will be defined by the joint self-government of hospital representatives and representatives from statutory health insurance funds by the end of June 2018.
Simon, Michael (2014): Personalbesetzungsstandards für den Pflegedienst der Krankenhäuser: Zum Stand der Diskussion und möglichen Ansätzen für eine staatliche Regulierung. Ein Diskussionsbeitrag. Available at: http://f5.hs-hannover.de/fileadmin/media/doc/f5/personen/simon_michael/Simon_-_Paper_Personalbesetzungsstandards.pdf
Federal Ministry of Health: https://www.bundesgesundheitsministerium.de/ministerium/meldungen/2015/expertenkommission.html