Primary Care in Germany

By Prof. Dr. med. Erika Baum
General Practitioner in a rural group practice
Head of the department of General Practice, University of Marburg, Germany
Vice-president of DEGAM (German College of General Practitioners and Family Physicians)

 
In Germany, all citizens including their children have to choose among 156 statuatory health insurances if they are employed and earn less than 3750,- EUR per month or get social welfare. All other citizens can opt for this system [1]. Nearly 90% of the German population are members of these insurances [2], the remainder mostly opting for private insurance. 

Within the statuatory health insurance, 93% of the population visit at least one physician resulting on average in 18 physician-patient-contacts per year. 68% have at least one contact with a general practioner (GP) in this time-frame [3]. A general practitioner in Germany sees on average 243 patients per week (31,4 hours of direct patient contact) and has a total workload of 50,6 hours per week [4], both indices being considerably higher than in many other comparable systems.  

Among the 420 000 working physicians in Germany, 43% work in ambulatory care with increasing numbers of specialists (now 77 000) and slightly declining number of GPs (60 000 in 2010). All these doctors are members of the statuatory health care system [5]. Since 1993 only physicians with successful postgraduate training can opt for this system. Now, the minimal training period for GPs is five years, as for most other specialities [6]. Germany is devided into 400 planning-regions and one can work with a new formal registration only if physician coverage does not exceed 110% or if another physician is replaced [7]. More than 50% of the regions in Germany provide vacancies for new GPs-practices, but very few for specialists [8]. In rural and underprivileged areas, it is inceasingly difficult to attract physicians and especially GPs to replace retired physicians [9]. Although there is special funding, the number of GPs in vocational training is not adequate for covering the actual demand. The income of GPs amounts to about 110 000 EUR/year, but it is lower than that of specialist [10]. Additionally GPs are currently a minority within the system of professional self-regulation, which has negative repercussions for Primary Care. Besides that, legal and internal regulations in regard to the payment system are changing rapidly. 

Patients have free access to any physician within the German system and have to pay each 3 months 10 EUR for the first contact with a given practice. They do not have to pay a charge if they are referred. In fact, when requested they normally get referalls without restrictions from nearly all GPs and specialists. So it does not matter, whether they contact a GP or a specialist first. Waiting times are moderate [11] and trust in physicians is very high with GPs achieving the best results [12].

21 out of 36 medical faculties in Germany have institutionalized departments of general practice with a professor as head of department, 5 lack any scientific posts [13]. The impact of general practice on undergraduate training is increasing. Especially the mandatory elective in family medicine (normally lasting 1-2 weeks depending on the given University) is appreciated and evaluated positive by students.

Germans are known to complain about their situation, and this is also true for GPs. This has an adverse effect and does not attract young collegues. In order to get more newcomers into general practice, integrated models for vocational training are piloted and out-of-hour-duty is restructured in a way that is less demanding for practitioners in rural areas. Additionally, it is now possible to create consortiums and employ collegues instead of running single or small group practices. Practice nurses should take more tasks and it would be better to ameliorate cooperation instead of competition between the different players in the German system.

 

 
[3] Barmer-GEK-Arztreport 2010
 
[4] K Koch, U Gehrmann, PT Sawicki: Primararztliche Versorgung in Deutschland im internationalen Vergleich. Dtsch Arztebl 2007; 104: A 2584-91

[8] T Kopetsch: Bedarsplanung: Lucken bei haus- und Facharzten. Dt. arztebl. 2009, 543