Karl Lauterbach calls the reform of hospital structures a 'revolution', which is currently bringing far-reaching changes to hospital care in Germany. Since the Hospital Care Improvement Act (KHVVG) in particular has been ‘finalised’ (BMG), many hospitals (at different speeds in the federal states) have been busy implementing the now certified groupers (software algorithms for calculating flat-rate remuneration), among other things.
This can sometimes have far-reaching consequences for personnel planning, as remuneration is no longer based solely on flat rates per case (DRG - Diagnosis Related Groups), but now also on flat rates per contingency. This is intended to cover the fixed costs of hospitals and allow them to ‘maintain’ essential structures and staff. In theory, this would allow hospitals to plan more long-term and more stable, as part of the funds (approx. 60%) no longer depend directly on the number of cases.
Unneeded additional services, which hospitals have sometimes billed for, would thus be eliminated. This is also because hospitals will be divided into different service groups and ‘certified centres’ will be designated for special medical interventions. Quality standards are to be defined transparently in this way. (More on this here.)
Outpatient care could (at least in theory) also be billed better. This would save beds and staff. The pros and cons are outlined here, as funding is a matter for the federal states and is therefore not standardised, while at the same time it is not very flexible for the individual hospitals.
This also results in a new structure for doctors, as they can no longer provide specialised services in smaller hospitals, for example, if they are not certified. This could make smaller, non-specialised hospitals less attractive.
It is therefore doubtful that restructuring and possible hospital closures will result in redundancies. Highly specialised head physicians will go to the centres with the highest qualification level and will be able to do little for junior staff, while specialist training will be the responsibility of the lower levels. The Marburger Bund criticises: ‘Linking further training primarily to one level of care would lead to poorer quality care.’
Challenges of restructuring and opportunities for investment
Smaller hospitals, such as Teterow Hospital in Mecklenburg-Western Pomerania, would lose their specialisation and thus a large proportion of their funding.
Hospitals must therefore develop innovative strategies to attract and retain staff. This includes attractive working conditions, benefits, training and further education programmes as well as measures to reconcile work and family life. However, without sufficiently qualified staff, the objectives of the reform, in particular the improvement in the quality of care, cannot be achieved.
Especially in the transition phase, until the reform has become established, finance and HR departments will have to work closely together to continuously monitor the financial situation. The management consultancy EY therefore recommends that hospitals carry out an internal analysis of their range of services and ‘take all measures to retain and attract specialist staff...’. Hospitals must therefore adapt their budget planning to the new remuneration structures and ensure that sufficient funds are available for staff recruitment and development.
However, there is a pay rise for doctors, which is long overdue, as the Marburger Bund writes and therefore welcomes the planned scientific testing of a staff assessment tool for doctors. The situation is similar in the care sector. In order to improve working conditions in nursing and determine the real need for nursing staff, the reform also introduces new standards for staffing levels, for example.
Staffing levels in care, PPR 2.0 and the shortage of skilled workers
The Nursing Staffing Regulation (PPR 2.0), which has been in force since July, 1st 2024, stipulates how many nursing staff must be deployed in relation to the number and severity of patients. Hospitals are legally obliged to comply with these requirements, which has a direct impact on staff planning. Compliance with PPR 2.0 requires a precise analysis of staffing requirements and, if necessary, the recruitment of additional specialist staff. However, some facilities report that only 45 to 60% of the current staffing requirements can be met because the shortage of skilled staff is so great.
This regulation was also introduced to reduce the overworking of nursing staff. As the shortage of skilled staff is already one of the most serious problems in the healthcare sector in Germany and is being exacerbated by demographic trends among both patients and doctors, the Asklepios clinics conclude: ‘At the end of the implementation of PPR 2.0, however, there will once again only be the realisation that there are too few nursing staff.’
The Association of Substitute Health Insurance Funds therefore believes that 'phantom nurses' are already being financed, which would inevitably jeopardise patient care. Instead, nursing potential should be developed, various associations demand in a joint analysis of the government commission. Recruitment from abroad is not enough.
Nevertheless, it is a further step for hospitals to recruit and retain staff. International specialists can be trained well in Germany if information is provided in English and German courses are offered.
Finally, digitalisation should also be expanded. The Asklepios clinics press release mentioned above states: ‘We also agree with the GKV head association's call for more standardisation and digitalisation in the assessment of nursing staff requirements.’
Opportunities through digitalisation
Despite all the criticism, hospitals need to start planning now and can be supported by software. The structural reform itself is also analysed using a digital tool, as vdek describes. The digital patient file can certainly be seen as a positive aspect of the overall ‘revolution’ and could be further incorporated to reduce documentation and administrative work. Digital assistance systems can also significantly reduce the shortage of skilled nursing staff.
At the moment, it seems that hospitals are mainly dealing with the changeover to the new structures. The Hartmannbund therefore believes that the digitalisation of hospitals is at risk as a result of the hospital reform.
However, with the new legislative period and a new federal government, an impact analysis as requested here could once again bring movement to the reform and remedy points of criticism. For personnel planning, it seems necessary to rely on digital tools and react as flexibly as possible to the current situation. In times of uncertainty and fragility (VUCA/BANI), hospitals could acquire new skills in open or transformational corporate management and thus create a new attractiveness for future generations.
Conclusion
There is no question that hospitals in Germany are in need of reform. Too many hospitals are in the red and have underutilised beds, as rnd describes here.
However, the transitional period until the hospital structure reform and PPR 2.0, which have now come into force, are successful appears to present hospitals with both financial and bureaucratic hurdles. It is doubtful that the restructuring will change the problems of the shortage of nursing staff and skilled labour in hospitals in the short term. In the long term, a change in remuneration including staffing levels for the nursing and medical professions may very well bring about an improvement, both through the pooling of specialist staff and through extended outpatient care. Until then, it seems to be up to the individual facilities to analyse their own financial and personnel situation, to retain employees and to create incentives for future generations and the future of the facility.
