The above chart, shown at yesterday afternoon’s Downing Street press conference, demonstrates the remarkable disparity so far between the death rate from the Coronavirus in Germany and in four other European countries, Spain, France, Italy and the United Kingdom.
It is now a week and a half since Charles Moore examined this discrepancy in his Daily Telegraph column:
“Most NHS staff are dedicated people. The defects are baked into our system of national bureaucratic command. People have noticed that Germany has been more successful in managing the virus spread through testing. This is not a coincidence. Germany does not have our lumbering central diagnostic system, because it does not have, in our sense, a national health service. It has 176 testing centres, part of localised arrangements which mix private insurance, employer involvement and government funding. There are more than three times as many beds per 1,000 patients as in Britain.”
Moore is correct. The discrepancy in intensive care beds is even greater: at the start of the pandemic, Germany had 34 for every 100,000 people, the European average was 11.5 and the United Kingdom had 6.6.
And Germany does not have a centralised system of command and control. Each of the 16 federal states has responsibility for health, paid for from a system of compulsory health insurance dating back to Bismarck’s Health Insurance Bill of 1883.
Germany today has a bewildering variety of public and private health insurance funds, with charges split between employers and employees, and supplemented by government subsidies.
The whole thing works by means of an elaborate system of corporatist bargaining, to set payments and entitlements.
But it also works because of a general consensus, among the German public, that one ought to be able to go pretty much immediately to whichever doctor one chooses.
The British assumption, that one can only get to a specialist via a general practitioner, does not pertain. Nor does the idea that healthcare is something to be rationed.
You can go direct to the specialist of your choice, to treat whatever you suppose to be wrong with you. When I lived in Germany in the 1990s, I never heard anyone complain about waiting lists for treatment, or for rehabilitation, nor has this become a problem since.
Such responsiveness can only be achieved by having excess capacity. Staff and beds are underused, which when a crisis arises is a great advantage.
Germans love being able to go to the doctor whenever they feel the need, which tends to be more often than in countries where demand is damped down by the need first to get an appointment with your GP, and then by a queue to see the specialist to whom you are referred.
In Germany, medical staff are incentivised, under the insurance system, to carry out procedures for which there may be no pressing medical need, but for which payments will be received.
Stays in hospital tend to be longer, stents are more often inserted, and batteries of tests are ordered whether or not they are required in order to arrive at a reliable diagnosis, for whether or not the tests are needed, charges for them can be levied.
There is far more scope, under this system, for competition between different providers, and for individual initiative: no need to wait for orders from the centre before attempting to develop a test for Coronavirus, or for anything else.
In Britain, the central bureaucracy was inundated with offers of help from potential providers of tests or ventilators or protective equipment who were trying, in effect, to sell their services to a single customer.
In Germany there are many customers, which means that in a crisis, there is less danger of a logjam developing at the national level, with the most senior bureaucrats failing at first to admit the need for sudden change, and then overwhelmed by the sheer volume of decisions needed from them in a very short period of time.
As a senior German doctor told ConHome:
“Our laboratory efficiency and capacity is high because of a high degree of privatisation and competition. We are not at all centrally ruled, meaning that every federal state can adopt own health care rules within certain limits.”
We are not the only country to have noticed that the Germans were quicker than us to respond to the present pandemic, and much faster to develop the testing capacity which can be so valuable in arresting its spread.
The French have seen with alarm that their more Napoleonic approach was in some respects markedly less effective, are worried that their industry has become so hollowed out that it cannot respond to sudden needs for more tests or other equipment, and are studying Germany closely to see what lessons they can learn.
This subject should not be discussed as if, by a mere act of political will, one can import whatever aspects of the German system, or any other system, might seem desirable.
And not every aspect to the German system can be called desirable. It is much more expensive than the NHS: according to the Office of National Statistics, in 2017 the UK spent £2,989 per person on health, while the Germans spent £4,432.
To raise spending to German levels, while at the same time recovering from a severe economic shock, is unlikely to be practical.
Nor, cost aside, should one suppose the German system to be beyond reproach. It has yet to go digital, contains an excessive number of general hospitals which are short of medical staff, is bad at preventive health programmes and does not lead to better general outcomes.
It would be good to bring a degree of humility to this debate. Patriotism, the unthinking defence of one’s national way of doing things, is not enough.
Nor is ideology: the simplistic claim that either more privatisation or more nationalisation, either the free market or socialism, offers a complete answer.
West Germany was founded on the social market economy: a pragmatic combination of market economics with social provision. Competition and co-operation were combined in such a way as to command a consensus.
This was not very exciting to write about. The consensus only seemed to be kept on the road by means of endless, dreary negotiations, in which no one was entirely honest about the interests they were trying to defend.
But at least the politicians of West Germany recognised, as they worked out how to run their health system, that in order to meet the needs of patients, and command public approval, there had to be an entrenched role for competition between different providers.
This is a concession the founders of the NHS made only with reluctance, and spent many years trying to extinguish or restrict. Our system is more monolithic than the German system, and critics of its over-centralised character are liable to be seen as so disloyal that they are accused of wishing to sell it off to the Americans.
In the NHS, the patient can all too easily be made to feel like a supplicant, who has no real rights, and should be grateful for what he or she is given. In Germany, where the patient has far greater freedom to go straight to a particular doctor, that debilitating sense of inferiority, even of impotence, is much less likely to arise.
Boris Johnson has seized the chance to embrace the NHS. The next step, once the immediate crisis is past, must be to see how it can be made more flexible and resilient, and that means we cannot just lose ourselves in boundless admiration for the NHS’s staff: we have to look at what we might be able to learn from Germany.