The position of the German government that "private is better than state" in the hospital system provides solely for sound profits to the managers. The personnel does hard work for that, the patient is needed mainly to pay

Financial problems, personnel reduction, overtime, rush work – the situation in German hospitals is getting ever worse. While in the last ten years, about 10 percent of all hospitals closed, 20 percent of beds were thrown out and about 100,000 jobs in hospitals eliminated, the number of patients as well as the investment needed has grown steadily. Instead of adapting expenditures to mounting need, politics and business put their stakes in privatisation and more "competition" in the health sector. The victims of this development are the patients as well as the personnel in the hospitals who for meager incomes are exploited ever more mercilessly. Yet, the resistance against the neoliberal savings dictate is growing: Under the slogan: "Away with the cap! Decent financing of hospitals", a demonstration will take place in Berlin today against the limitation of the budgets and for a better financial equipment of the hospitals.

Overtime and paper work

The work-load in German hospitals has become unbearable. Between 1996 and 2005, almost 100,000 full-time jobs in the clinics were eliminated; about half of them in care. Of course, the number of hospital beds in this period was reduced by about 20 percent. However, since the share of patients has risen by 15.5%, this only means that less and less time remains for admission, examination, care and release of patients. Added to that is the fact that the bureaucratic red-tape needed since the transfer to a system of case-based lump sums or diagnosis related groups (DRG) in the year 2004 has grown immensely, so that doctors and personnel need to spend ever more time with the filling out of forms.

In 1995, one nurse or caretaker on average had six patients to take care of. Ten years later, that amount had already doubled, today it is 20 patients that a nurse needs to take care of daily. As the Deutsche Pflegerat (German Care Council) declared on 16 September, the bleeding and exploitation of care personnel have passed frontiers that mean the end to a qualitatively safe care of the patients. Of course, "health" minister Ulla Schmidt (SPD) now announced that she wants to create 21,000 new jobs in care – which as compared to the cynical proposal to employ 10,000 long-term unemployed for the care of dementia patients already means a progress. However, even 21,000 jobs would only be a fraction of what was eliminated over the past years in terms of care personnel. Added to that is the fact that not only the nurses, but also the doctors in the hospitals suffer from extreme overwork. Following data by the physicians trade union, Marburger Bund, clinic doctors every year supply 56.6 million hours in over-time; weekly work times of over 70 hours are no longer the exception. By way of normal duty and subsequent stand-by duty, employees in the hospitals are often on the job for up to 32 hours in a row. Of course, the European Court of Justice in 2003 decided that also stand-by duty needs to be considered as full work-time. In the meantime, however, the 27 labour ministers of the EU, have agreed on a new work-time directive, according to which the "inactive part" of stand-by duty now after all need not be considered as work time and the weekly work time in "exceptional cases" may run up to 65 hours. Welcome to Manchester capitalism....

Need orientation instead of profit orientation

The origin of today's emergency situation of the hospitals is to be found in a policy of cuts practiced over many years that has taken contributions in the billions from the clinics and forced them to drastic "adaptations" in the form of personnel reductions and eliminations of beds. The central instrument in creating neoliberal savings constraints turned out to be the limitation of hospital budgets. That means that the expenditures of the clinics for personnel, medical supplies, electricity, food etc. may not go up more than the incomes, for which the medical insurance payments are paid. Because the health insurances due to high unemployment and an increase in precarious employment suffer from revenue losses, there is a trend towards lowering the sum that may be used for the financing of hospitals.

This "cap" was introduced by way of the health structure law adopted in 1993. Up to then, there the principle of cost-coverage was valid in hospitals, meaning the expenditures for the operating costs of the hospitals were in line with the respective amount required for guaranteeing a qualitatively high-value hospital care. By way of the health structure law, this need orientation yielded the way more and more to a profit orientation that pursued the goal, on the one hand, to keep the contribution rate to the health insurances stable, on the other hand, was supposed to drive forward economic management and the rationalisation of hospital operation and to provoke more "competition". These goals – lowering of non-wage labor costs for firms and more competition in the "service sector" - were confirmed one more time explicitly by the neoliberal Agenda 2010 and the so-called Lisbon strategy of the European Union.

Of course, there can't be any objection against efficiency increases in the health system. However, the basic problem is that in the meantime no longer the needs of the patients, but business indicators which measure first of all the extent of cost reduction and profit increase, are in centre stage . The result is not necessarily more efficiency in the health system, but a redistribution of resources at the expense of patient care and to the advantage of management, advertisement, consulting and administrative action. Moreover, a private health system will concentrate on rich patients, while for poorer population groups by way of consultation fees and ever more additional fees, it gets more and more difficult to make use of medical services at all. The principle of a comprehensive supply as well as the aspect of prevention measures without a fee, in a profit-oriented system are lost out of sight.

The budgeting of hospital expenditures also serves as an entry into a two-class medicine . Since the treatment of private or foreign patients is compensated outside the budget, the clinics have a great incentive to orient their services towards precisely these groups. This privileged treatment of private patients is all the more unjust, since almost the complete infrastructure of the hospitals is financed from tax means and the contribution payments to the health insurances.

In the second half of the 90s, the cap of hospital budgets was pushed down; at the same time, it became more and more difficult to compensate the brutal pressure for savings by way of economic efficiency or further rationalisation. The situation was dramatically exacerbated in the last couple of years: despite rising value-added tax rates, rising energy prices, and continually rising prices for medication and medical equipment, the budgets of the hospitals have hardly been increased. At the same time, also the increasing exploitation of hospital personnel ever more clearly reached its limits – one may remember the first physician's strike in over 30 years in the year 2006, or the large strikes in the public service, in which also many hospital employees participated . In the meantime, almost every third clinic is in the red; that means, if nothing is changed about the systematic under-financing, many hospitals will be forced next year to fire more personnel, to drastically reduce their services or to completely terminate their operation. Of course, the federation and the regions in the meantime decided to give next year 3 billion additional Euros to the approxiamtely 2100 hospitals. In the light of the additional need that for 2008 and 2009 is calculated at 6.7 billion Euros, this would only be a drop in the ocean; moreover, you can hardly solve the structural problem of underfinancing of hospitals by way of such a one-time payment.

Apart from this under-covering of operating expenses, the hospitals also lack the needed money for investments, since the federal states have retracted more and more from hospital financing. In between 1997 and 2007, the investments of the states in the hospitals have sunk from roughly 3.6 to 2.66 billion Euros. Following calculations by the German Hospital Society, the investment bottleneck in German hospitals in the meantime runs up to 50 billion Euros. Last but not least, neoliberal tax policy is responsible for that: the elimination of the wealth tax – a tax that benefited exclusively the regions and, in 1996, still washed 4.6 billion Euros into the cash registers – contributed considerably to the prevention of needed investments.

If the financial situation of the hospitals is not soon adapted to the real need, quite a few of them will hit insolvency.

FRG: pioneer in hospital privatisation

This process would speed up the privatisation of hospitals – quite in the sense of the neoliberal creed: Private is better than state. This while Germany is already now pioneer in the matter of the privatisation of the health system: No other country in the last couple of years has sold so many and such large clinics to the private sector. In the meantime, Germany has surpassed the USA as far as the profit orientation in the hospital system is concerned. Of course, still roughly half of the hospital beds are in public ownership. On the other hand, the share of private institutions among all hospitals has jumped, between 1991 and 2007, from roughly 15 to 28.5 percent, while the share of public hospitals has sunk from 46 to 33.7%. The share of hospitals in free ownership has also slightly declined: from 39 (1991) to 37.8 percent (2007). Among the profiteers of this privatisation wave are companies such as the Rhön Clinics Inc., Fresenius Helios, as well as the Asklepios Clinics ltd. which in the meantime lead the list of the largest European hospital companies.

Privatisation of hospitals means that profits are withdrawn from the publicly financed health system and extorted from the employees. That way, privatisations among other things result in undercutting the collective agreement-based wages of public firms, which is possible due to the lower level of trade union organisation in private or non-profit hospitals. In the meantime, however, also the public and the non-profit hospitals respond to the increased competitive and cost pressure by reducing their personnel and subcontracting or "outsourcing" ever more areas (from computer logistics to the cleaning system).

The victims of the neoliberal privatisation policies are last but not least the patients: That way, following privatisations, one can often notice a dramatic loss of quality in care levels. In the university clinics of Gießen and Marburg, for instance, since the privatisation in the year 2006, about 500 full-time posts have been eliminated. The consequence: patients can no longer be washed daily and bandages are no longer changed regularly, and at night, in a whole station at times no trained person can be found any longer that could take care of possible emergency cases.

If things go according to the wishes of the private hospital operators, then the "competition" in the health system would be geared up even further: elimination of state financing of investment costs, complete competition for patients and services, abolition of regional hospital planning, ending of quotas for bed numbers and the service level, elimination of deficit compensation among public owners, end to tax advantages for non-profit public hospitals – this and other "reforms" for a long time have already been on the wish lists of the federal association of German private hospitals. In order to better impose their own interests, private clinic operators in the meantime called the EU Commission for help to take measures against the "distortion of competition" by public hospitals. At this point, the EU Commission even contemplates a procedure for treaty violation against Germany, because it might be an impermissible state aid if deficits of local hospitals were covered by the local community as owner. Yet, not only the EU, also the monopoly commission of the German federation in its current yearly expertise demands "less state" and "more competition" on the "medical market", which in the year 2005 had a volume of 239.4 billion Euros, of which again 62.1 billions arrived at the "hospital market". That way, the monopoly commission considers "the central hospital planning done by the federal regions an important obstacle to innovation and efficiency in the hospital sector". Instead, this planning should concentrate on the "guarantee of only an indispensable basic supply", while the rest should be left to the market. It is in line with this orientation towards a two-class medicine that the monopoly commission also criticises the "existing legal full-insurance system", since it results in patients in their demand for medical services let themselves be guided "solely by qualitative criteria", while ignoring the costs.

However, the monopoly commission itself acknowledges that there cannot be talk of a competition in the hospital system, or respectively, that such a competition at fixed prices takes place at the expense of the quality of care. Added to that is the fact that the "free choice" among various "service offerings" for most sick people does not even play a role, because they go for treatment simply to the hospital next to them. The so-called guardians of competition have nothing against the fact that in the private sector, four big hospital companies dominate the market – on the contrary: the threshold after which hospital fusions are supposed to be classified as detrimental to competition is even supposed to be clearly increased according to the proposal of the commission.

E-Card and the transparent patient

Yet, not only "competition" in the hospital system is a mere chimera. The same holds for the much-quoted "cost explosion" in the health system, by which drastic savings measures are justified over and over again. For instance, the share of health expenditures in the Gross Domestic Product between 1995 and 2005 just rose from 10.1% to 10.7% - the share of expenditures for hospitals even declined slightly. Therefore, it is in no way the case that there is basically no money for the financing of a need-oriented modern health system. Redistribution takes place only according to neoliberal principles, that is, money wanders from the taxes of the tax payers and the employed into the pockets of profit-mongering pharmaceutical companies, health managers, consultants and private service corporations.

The best example of that is the introduction envisaged by way of the health reform of 2003 of the Electronic Health Card, which will certainly devour a couple of billion Euros, since all hospitals, physicians' cabinets and pharmacies need to be equipped with corresponding reading equipment and the appropriate software. The industry which for years has been pressuring for the quick introduction of the so-called e-Card is particularly interested in it and refers to the numerous advantages that would be linked with its use: The costs for prescriptions would be lowered, unnecessary double examinations reduced, as well as the risk of false medication; moreover, the exchange of data between doctors, health insurances, pharmacies and patients would be easier and more efficient. Later on, there are also supposed to be commercial "value-added applications", in which the pharmaceutical industry might have an especially great interest.

In order to have an "added value" over the present system, medical data in the future must be deposited on large data servers and stored. However, who guarantees that these sensitive data will not ever get into the wrong hands? What if data is stolen, or the laws at one time are such that also insurances, pharmaceutical companies or interested authorities may access the data? And would it not be more reasonable to use the billions foreseen for the e card for the creation of jobs in care, instead of subsidising firms like IBM, Siemens or the Bertelsmann daughter Arvato with big contracts? Luckily, these and other questions thanks to the latest data scandals again are being discussed more intensively; that way, there is the hope that the expensive and dangerous prestige project can still be stopped. On the website: stoppt-die-e-card.de that is operated by an action-oriented alliance of data guardians, as well as physicians and patient associations, already more than 400,000 signatures have been collected.

Alternatives are possible!

What can one do against the neoliberal reconstruction in the health and hospital system? On the one hand, everything must be done in order to reverse the trend towards the privatisation of hospitals, for instance, by supporting corresponding citizens' petitions and popular referendums against privatisation. Where clinics have already been sold – such as, for instance, in the case of the regional enterprise Hospitals Hamburg (LBK) or the university clinics Gießen and Marburg – we need to struggle for a recommunalisation, for instance via the retransfer into public ownership.

At least as important is the struggle for better wages and working conditions, an increase in the number of care personnel, as well as the urgently needed investments into the hospitals. Even if the financial problems of some federal states caused by the neoliberal tax reforms cannot be disputed, it is not acceptable that the states hardly follow suit to their obligation for the upkeep and the extension of the health system. In order to improve the financial situation of hospitals – just as of out-patient care – and to achieve a need-oriented, territory-wide health system aimed at prevention, ultimately the whole financing (and organisation) of health services must be newly regulated.

The health fund planned for 2009 will certainly not do away with the wrong developments and deficits in the German health system. For instance, the plans of the federal government envisage that the insurances in the future – if they cannot carry their costs with the means from the fund – may levy additional payments that need to be paid only by the insured and not by their employers. As if the insured were not already burdened with enough "supplements" for medications, preventive care, dental replacement etc.! The central principle of left health policy is that all medical services need also to be available to people with low income. For this reason, not only the antisocial consultation fee needs to be abolished; also medically necessary services such as glasses or dental replacement must again be fully funded by the insurances.

As far as the financial side is concerned, it remains worthy of criticism that the private insurances do not participate in the financing of the health fund – however, precisely that would be necessary to counteract the trend to a two-class medicine and to finally be able to solve the financing problems. Instead of artificially fueling the competition between different insurances, private health insurances would need to be abolished completely in the future and a unique and solidary health insurance should be introduced to whose financing both the companies as well as rich private persons would have to make an appropriate contribution.

Of course, these goals won't be reached from one day to the other. Even a defence against privatisation will only be possible if we succeed to forge broad alliances with employees, trade unions and other social organisations. As the alliance for the rescue of hospitals has already proven, quite a number of concessions can be extracted by way of strong protests and common mobilisation. We now need to develop this mobilisation by linking the protest against a hospital policy based on savings to death with resolute protests against privatisation and de-solidarisation tendencies in the health sector.

Jürgen Klute and Sahra Wagenknecht are members of the executive of the party The Left and active in the working group "Anti-privatisation"