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How unhealthy habits are putting pressure on Germany’s healthcare system

Healthcare in Germany has been praised in a global study – but Germans are still battling bad habits.

How unhealthy habits are putting pressure on Germany's healthcare system
Revelllers raise a beer at Oktoberfest in Munich. Photo: DPA

According to the OECD Health at a Glance 2019 report, Germany is among the top five spenders on health care, both as a proportion of GDP (11.2 percent) and per person ($5,986). 

And health spending is projected to further increase to reach 12.3 percent of GDP by 2030.

The report said: “With such high level of spending, Germany guarantees good access to health care services, with a widely available health infrastructure, a high number of health professionals and relatively broad coverage for the costs of health care.”

However, Germany has mixed results when it comes to health outcomes.

Life expectancy for people in Germany is at 81.1, making it 10th in the list of developed countries and above the OECD average of 80.7, but behind Japan which snags the top sport, with a life expectancy rate of 84.2.

READ ALSO: The 20 key stats that help explain Germany today

Unhealthy habits in Germany also remain widespread. Germans on average consume more pure alcohol – 11 litres per year – than the OECD average of 8.9.

To compare with neighbouring countries, the amount of litres of alcohol consumed per year in France is 11.7,while in Austria it's 11.8, and in Switzerland it's 9.2. The countries that consume the lowest amount of alcohol are Turkey, Israel and Mexico (all under five litres).

In Germany, 60 percent of the adult population is more likely to be overweight or obese – that's higher than the OECD average of 55.6 and far greater than in France (49 percent), Austria (46.7 percent) and Switzerland (41.8 percent).

Meanwhile, the share of adults in Germany who smoke – 19 percent – is higher than on average across the OECD, although it's worse in other countries, such as France where the proportion is 25.4 percent.

READ ALSO: Opinion: Why Germany needs to take the smoking ban more seriously

Photo: DPA

Looking at the big picture, smoking rates range from over 25 percent in Greece, Turkey and Hungary, to below 10 percent in Mexico and Iceland.

Germany has a high rate of diabetes. A total of 8.3 percent of the population has diabetes, compared to the OECD average of 6.4 percent. In France, that figure is 4.8 percent, in Austria it's 6.4 and it's 5.6 in Switzerland.

Overall, the report found that 8.4 percent of the population are in poor health, slightly better than the OECD average of 8.5 percent.

Preventable deaths

The OECD researchers say that Germany's unhealthy habits, like drinking too much alcohol and smoking, are contributing to preventable deaths. 

Around 120,000 people died in Germany in 2016 from preventable causes such as lung cancer or alcohol-related causes.

The OECD said this “could be avoided through effective public health and primary prevention interventions”.

While the mortality rate for these causes in Germany is 10 percent below the OECD average, it is substantially higher than in many western European countries, such as Switzerland or the Netherlands.

“Although progress has been made in reducing risky health behaviours, Germans are still more likely to smoke and consume more alcohol than the OECD average,” the report said.

“In 2017, nearly 19 percent of German adults smoked daily. This is down from 23 percent a decade earlier but still much higher than in Sweden or Norway (10-12 percent).”

The report suggested Germany take further measures to combat drinking alcohol and smoking, such as a complete ban on tobacco advertisement.

READ ALSO: Germany should take drinking tips from Scotland, experts insist

High number of doctors and nurses

Things look good when it comes to access to healthcare.

Compared to other OECD countries, Germany has a high availability of doctors and nurses. There are 4.3 practising physicians (OECD average is 3.5) and 12.9 nurses (OECD average is 8.8) per 1,000 population. 

However, there are regional differences, with rural areas less well served. When it comes to doctors, Germany has a relatively low and decreasing proportion of GPs who “play a key role in addressing the needs of an ageing population,” the report said.

This comparably high supply of health workforce needs to be seen in context with the very high health care activity, particularly hospital activity. With 255 hospital discharges per 1,000 population, Germany has the highest rate of inpatient activity among all OECD countries – more than 60 percent above the OECD average. 

READ ALSO: Germans turn to 'medibus' as doctors desert villages

As a result, the workload of some health workers in Germany is high. For example, in hospitals there are fewer nurses per bed than in many neighbouring countries.

A number of policy measures to address this issue and improve working conditions of nurses have been implemented recently. These include the introduction of minimum nurse-to-patient ratios in some areas in hospitals and making additional funding available for hospitals to increase nursing staff.

Germans visit doctors more often than other countries

Germany has the fourth highest share of the population over 65 in the OECD countries, with a growing number of people affected by chronic conditions.

The report said hospitalizations in the Bundesrepublik “are high for chronic conditions such as diabetes or congestive heart failure, that should effectively be dealt with in primary health care”.

Germans also consult doctors in the outpatient sector more frequently than people in most other countries. Demographics and the wide availability explain some but not all of the higher utilization rates, said the OECD.

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HEALTH

EXPLAINED: What to do if you face a long wait for healthcare in Sweden

Sweden theoretically has a "healthcare guarantee" limiting your wait to see a GP to three days, and to see a consultant to three months. The reality is somewhat different. Here's what you can do if you face a long wait.

EXPLAINED: What to do if you face a long wait for healthcare in Sweden

What is Sweden’s ‘healthcare guarantee’? 

Sweden’s “National Guaranteed Access to Healthcare” or vårdgaranti, is a right to care, protected by law, that has applied in Sweden since 2005. You can see the latest version of the relevant laws here and here. Here is a summary of the guarantee on the website of the Swedish Association of Local Authorities and Regions (SKR).

Under the system, all patients are guaranteed:

  • contact with a primary care centre by phone, in-person, or by video-link on the day they seek care 
  • an appointment with a doctor, nurse, physio, or psychotherapist within three days of seeking help 
  • an appointment with a specialist doctor or consultant within 90 days of seeking help 
  • treatment or operation within 90 days, if the specialist considers this necessary 

Does the guarantee mean I have a right to treatment? 

No. If the doctor at the primary care centre, after examining you and questioning you, decides that there is no reason to refer you to a specialist doctor, they do not need to do so. 

Similarly, if the specialist doctor, after examining you, decides that no treatment is necessary, then your case is considered completed.  

Can the waiting times to see a specialist or to get treatment be longer than 90 days? 

Absolutely. In fact, they very often are. 

According to the Swedish Association of Local Authorities and Regions (SKR), in February, 32 percent of patients had been waiting 90 days or more to see a specialist, and 43 percent of those who had seen a specialist had been waiting for treatment for more than 90 days.  

The situation in primary care was a little better, with 80 percent of those seeking care in contact with their primary care centre on the same day, and 83 percent having their case assessed by a doctor or nurse within three days. 

In addition, if you agree with your specialist doctor that you are willing to wait longer for an operation, then that wait doesn’t get counted in the statistics. 

So what can I do if I’ve been waiting longer than the guaranteed time? 

In reality, it’s actually less a guarantee than a target.

In primary care, there is no way for individual patients to complain that they have had to wait too long to see a doctor or nurse, or to cut their waiting times by citing the guarantee. 

“There’s no system for enforcing that guarantee,” says Emma Spak, the primary care doctor who doubles as section chief for SKR’s healthcare division. 

It would make no sense to set up a complaints line for those who have had to wait too long for phone contact with their primary care centre, she points out, when they could instead talk to patients seeking a primary care appointment in the first place. 

“It’s more of an incentive system for the regions,” she explains.

Every primary care unit and every region reports their waiting times to the national waiting time register, and then as part of the access agreement between SKR and the government, the regional health authorities receive a bonus if they meet their waiting times goal, or if they improve their waiting times. “That’s one way of sort of enforcing this guarantee,” she says. 

When it comes to specialist treatment, though, patients do have the right to demand to be examined or treated by an alternative specialist or hospital if they’ve had to wait longer than 90 days.

If your primary care centre issues you a referral to a specialist, and the specialist cannot then offer you an appointment within 90 days, the specialist, at the same time as offering you a later appointment, will often put you in contact with a unit at the regional health authority who will offer to find you an alternative specialist, either within the region or elsewhere in Sweden. 

The regional health authority will then have to reimburse any extra travel or hotel costs incurred by the patient.  

Similarly, if after examining you, a specialist cannot offer you treatment within 90 days, they will normally put you in contact with the same unit. 

Some regions have a phone line for people who have been waiting too long, or else you can contact your specialist or primary care centre and ask for information on seeking an alternative specialist. 

What happens if I don’t want to travel to see a specialist or get treatment? 

If your regional health authority offers you an alternative specialist, either within your region or in another region, so that you can get treated within the 90 day period, and you are unwilling to travel, then you lose your rights under the guarantee. . 

“If you’re in Gothenburg, and they say you have to go to Stockholm to get your treatment, and you say, ‘no, I want to go here, then then you’ve sort of forfeited your right, and you have to take what’s on offer,” Spak says. 

What happens if I agree with my specialist to wait longer? 

If your specialist says that they can treat you in four months, but also offers you treatment elsewhere within the guaranteed 90 days, and you choose to be treated by your specialist, then that counts as a patient choice, which will not then be counted in the statistics. 

“The specialist might say, ‘I don’t think you will get any worse for waiting two months extra, and if you wait five months, then I can make sure that you get your surgery done here, and we can make sure that you get all the aftercare and everything here as well,” Spak says. 

But these patient decisions are also counted in the statistics, and if a region sees a sharp rise in patients choosing to wait, SKR will tend to investigate. 

“If some region all of a sudden has a lot of patients choosing a longer waiting time, then we will call them and ask what’s going on here, because patients don’t tend to want to wait extra,” Spak says.  

Can I get financial compensation if I’ve been waiting too long? 

No. 

What other ways are there of speeding up the wait for treatment? 

Don’t underplay your symptoms

When drawing up their timetable for treatment and assessment, specialists will tend to give different patients different wait times depending on the urgency of their case.

For this reason, it’s important not to underplay your symptoms when visiting a primary care doctor, as they will tend to include a few lines on the urgency of your case when they write their referral. 

Stress your flexibility 

If you are unemployed, a student, retired, or have a very flexible job, it is worth telling your primary care doctor about this, because they may write in your referral that you are able to make appointments at very short notice. The specialist may then put you on their list of people to ring if one of their patients cancels. 

“Sometimes I write in my referrals that this patient could easily come at short notice, so please put the patient on the list for people you can call if there’s a time slot available,” Spak says. 

If you haven’t told your primary care doctor this, it’s not too late. You can ring the specialist yourself and tell their receptionist that you are very flexible, and ask to be put on the back-up list. This is particularly useful if you’re waiting for a scan, but you could also potentially work even if you’re waiting for heart surgery or a hip replacement. 

“If they’ve accepted you as a patient, and they’ve made sure that you fulfil the criteria for having that scan or whatever, then you can call them and say, ‘I have a really flexible job, I can come anytime if you have a gap,'” Spak says.

“A lot of people do that, because they can have [back-up] waiting lists. If you tell them ‘I work around the corner and I only need 15 minutes to be there’, then they might call you if someone doesn’t show up.” 

Ring up your specialist 

The queue system tends to be quite ad hoc, with no strict rules over who should be treated first, so it is often possible to reduce your wait by ringing up your specialist a few times a month, just to bring your case to their attention. Sometimes the receptionist will remember a slot that has just come free and bring forward your treatment while you are still on the telephone. 

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