Healthcare reform has been a constant phenomenon for the last two decades, regardless of being Bismarckian or Beveridgean. The launch of new reforms has increased in pace to a point that was defined, in a recent BMJ article on the UK National Health Service, as ‘constant redisorganisation’. Most of the policy analysis literature on healthcare reforms has been of Anglo-American origin. Consequently, a study on the German health insurance based system is very welcome, indeed, long overdue.
Ellen Kuhlmann of the Centre for Social Policy research at the University of Bremen is a sociologist, engaged in the ‘Sociology of Professions’ network of the European Sociological Association. She is an able representative of the sociologist school of health professions research, and brings that perspective to her analysis of recent changes in the German healthcare arena. The study combines a descriptive analysis of the changes in the regulatory frameworks, a survey among German physicians, and focus group interviews with physicians, physiotherapists and surgery receptionists, the latter as representatives of rising and potential new professional groups, and interviews with patient self-help groups.
Germany differs from other European countries by having a system of predominantly corporatist regulation of health-care. The major players are the statutory health insurance funds and the physicians' associations. Health insurance funds cannot intervene in provider organisations. Recent changes in legislation, introducing some market elements, have not been able to overcome corporatist conservatism. Non-medical health professions are still excluded from the regulatory bodies. Although consumerism among patients and citizens has increased in Germany the government ‘cannot rely on patients as partners to control health care providers’. Kuhlmann suggests that consumerism is strengthening rather than weakening expert knowledge and promotes the expansion of professionalism into new areas. As the government has introduced new regulatory frameworks like technology assessment, quality assurance and clinical guidelines, physicians, who traditionally rely on self-regulation, have increasingly started to use those management tools as a strategy to boost public trust in their profession. As that trust is increasingly based on information and rational criteria like scientific evidence rather than authority or social status it, according to Kuhlmann, might lead to diminishing hierarchy in healthcare. That would open up for a more collaborative spirit among different health professions groups. On the other hand, it might also promote increasing specialisation into independent groups, weakening rather than strengthening collaboration.
What implications has this analysis of German healthcare for service integration? There are good news and bad news. The good news is that, given the strong position of physicians, if government and payers manage to create incentives to form clinical networks across organisational boundaries, it might well promote seamless care arrangements for patient groups. Physician-led, those networks might also employ other health professionals and create innovative services based on new models for division of work and responsibilities. The bad news is that new regulations could collide with corporatist conservatism and simple preserve status quo. German patients and citizens do not yet seem to be ready to start a revolution.
This book is well written. A non-sociologist reader enjoys the presentation of the German healthcare system and its recent development. The way it discusses governance issues is relevant to other countries as well. As an analysis of ‘modern’ and ‘post-modern’ influences on health systems and policies it is useful and generalisable. It is probably not a book, though, that one would like to recommend to a clinician reader, looking for easy-to-implement-recipes for integrated care. But a social scientist can convincingly make the case that there are no easy solutions.