Doctors on Strike — The Crisis in German Health Care Delivery
N Engl J Med 2006; 355:1520-1522October 12, 2006DOI: 10.1056/NEJMp068148
In mid-March 2006, physicians at Germany's university clinics went on strike, protesting an increase in the hours of the official workweek that came without a corresponding increase in pay. The physicians' union, the Marburger Bund, argued that neither the old official workweek of 38.5 hours, nor the new one of 40 or 42 hours, reflected the reality known by most doctors in Germany, where 80-hour weeks are common and physicians often put in many additional, uncompensated hours. About 15,000 of the 20,000 physicians based at university hospitals joined in this unprecedented strike.
After 3 months of collective action and negotiation, employers consented to pay increases of 8 to 18%, far less than had been sought. The Marburger Bund was successful in improving working conditions by reducing the actual weekly working time to a maximum of about 48 hours (with well-defined exceptions permitted under the derogations allowed by the European Union). Furthermore, the union secured bonus payments for physicians who have earned more advanced medical qualifications.
Then, in late June, physicians at German public hospitals followed their university colleagues onto the picket lines, staging rolling strikes at about 700 municipal clinics that together employ approximately 70,000 doctors. Demanding better working conditions and pay increases similar to those sought at the university hospitals, the Marburger Bund rejected an agreement that had recently been negotiated between the municipalities and the service-sector trade union Ver.di on behalf of all public employees, which the Marburger Bund said neither reflected the working patterns of physicians nor compensated doctors for wage losses. (For example, a married 29-year-old physician would have lost €31,000 over a period of 10 years and €68,000 over a period of 20 years.) This was the first time a group of highly qualified “public servants” had not agreed to contracts negotiated between public employers and the general public-service union. Late in August, after an 8-week strike, the Marburger Bund and the municipalities signed a new contract, granting doctors pay raises similar to those obtained in the university hospitals. Overall working time was limited, and better reimbursement schemes for overtime and night-call duty were accepted.
Physicians on strike — a phenomenon that would have been considered unthinkable — is now a reality. Yet given that many of the factors involved are the very ones that have contributed to a health care crisis in Germany, it seems likely that walkouts will become more common in the future.
To comprehend why German physicians have taken to the streets rather than staying at their patients' bedsides, one must understand the state of the German health care system and the way in which hierarchies and decision making have been restructured in recent decades. With a system based on social insurance, expenditures for health care represent 10.8% of the gross domestic product of Germany — higher than the average of 8.9% among the 30 countries in the Organisation for Economic Co-operation and Development. Ambulatory health care is provided by general practitioners and specialists, and inpatient care is delivered by a mix of public, nonprofit, and private providers. With one exception, university clinics are managed by the federal states. The population enjoys equal and easy access to care, and waiting lists and explicit rationing of health care have been unknown to date.
But social politics have continuously weakened white-collar professions, including those in medicine and pharmacy, detracting from the bargaining position of physicians employed by university and municipal clinics (who make up about 30% of all doctors in Germany). For example, in a trend reminiscent of that associated with managed care in the United States in the 1990s,1 during the past three to four decades the German medical profession has permitted health insurance companies to control many aspects of medical practice. This has changed the German concept of good and affordable medicine by placing ever-greater limits on doctors' latitude in making medical decisions for their patients. At the same time, medicine has been increasingly subjected to economic considerations. Increases in the costs of diagnostic and therapeutic procedures have coincided with the shrinking of the tax base. So physicians employed by university clinics and municipal hospitals have been forced to accept increases in their workload, coupled with ever-lower incomes.
Between 1991 and 2004, 1 in every 10 German hospitals was closed, resulting in a 20% reduction in the number of hospital beds. The length of stay in hospitals decreased by 38%, but the number of patients being treated increased by 20%. Thus, work in hospitals was condensed and intensified, and physicians' work hours increased accordingly. Not all physicians were unhappy with long working hours. Night calls were reimbursed and constituted the only chance for many, especially junior, physicians to earn a decent income. Others welcomed the overtime because it provided them an opportunity to perform enough operations and procedures to qualify for professional specialization quickly. But the average German physician was clearly feeling overworked.
The burden was growing by more than the number or patients assigned to each physician. In 2003, a survey found that physicians in German hospitals spent more than one third of their working time on documentation and other administrative duties. Traditionally, the German hospital system has made little use of coding assistants or advanced-practice nurses to perform routine nonmedical tasks.
In 2004, an international survey showed that the earnings of hospital-based physicians in 2002 were lower in Germany than in any other country under review (see graphAnnual Average Earnings of Hospital Doctors in 2002.).2 As Frank Ulrich Montgomery, chairman of the Marburger Bund, pointed out, the new wage agreement reached by Ver.di would have resulted in even further pay cuts for younger doctors.
It is therefore not surprising that only 55% of students who have recently entered medical school will eventually take a job in a hospital. Large numbers of German physicians have left the country to work abroad, primarily in Britain and Scandinavia. In opinion polls, German physicians emphasize that what they consider a crisis of the entire health care delivery system has been caused by several factors, including the loss of professional independence in clinical work, the increasing influence of economic considerations, and the growing load of bureaucratic tasks. There is a widespread feeling that even an increase in pay may be unable to restore the job satisfaction of physicians.
In the case of this year's strikes, the German Association of Municipal Administrations has argued that acceding to the Marburger Bund's demands would result in an “unprecedented avalanche of costs.” And indeed, about half of all local hospitals are allegedly operating in the red. Physicians participating in collective action are accused of jeopardizing the already tenuous existence of small hospitals, contributing to a worsening of the distribution of care, especially in rural areas. These complex problems must be addressed if we are to address the factors that underlie both the dissatisfaction of physicians and the overall crisis in health care delivery.
Dr. Nowak is the director of the Institute and Outpatient Clinic for Occupational and Environmental Medicine at the Ludwig Maximilians University and a deputy for Occupational and Environmental Medicine at Technical University — both in Munich, Germany.
Bramley-Harker E, Barham L. Comparing physicians' earnings: current knowledge and challenges: a final report for the Department of Health. London: NERA Economic Consulting, 2004. (Accessed September 20, 2006, at http://www.nera.com/Publication.asp?p_ID=2552.)
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