Inpatient care | Nursing is once again in the crosshairs

Since the pandemic, everyone should know: there is a nursing shortage in hospitals. However, the problem hasn't just existed since 2020; it has been simmering for some time. Staff at several hospitals across Germany have fought back, more or less successfully, by fighting for collective bargaining agreements to ease the burden.

Since 1995, there have been various trends in the absolute number of nursing staff in German hospitals. Initially, the number declined from 351,000 in 1995 to 298,000 in 2007. Then it rose again, with a significant jump in 2018. By 2023, there were 391,000 full-time employees (as a measure) in hospital nursing. The number of cases rose, with a slight dip in 2005, from 16.8 million in 1998 to 19.4 million in 2019. Since 2020, i.e., with the onset of the pandemic, the number of inpatients has fallen to a plateau of around 17 million, which has remained relatively stable. One of the reasons for this could be that many examinations and procedures are increasingly performed on an outpatient basis, including the treatment of breast cancer and hernias.

The introduction of case-based reimbursement groups (DRGs) in 2003, which introduced fixed prices for inpatient medical services, certainly had an impact on the decline in the number of nursing staff. These flat rates pushed hospitals to bill as many cases as possible while cutting costs. This was apparently most easily achieved with nursing staff. This is consistent with the fact that the number of full-time medical positions has risen continuously since 1995, from 101,000 to 177,000 in 2023.

"Fair wages and more staff are not a luxury."

Christine Vogler German Nursing Council

The sudden increase in the number of nursing staff starting in 2018 remains to be explained. At the end of 2018, the return of cost-reimbursement for nursing services was decided, and this came into effect in 2020. In light of the nursing crisis and the struggle for relief collective agreements, these costs were removed from the case-based fees. Hospitals could now hire staff as needed (although only for so-called "bedside care") and bill health insurance companies.

Economist Boris Augurzky, who co-publishes the annual Hospital Rating Report , also suggests that this care budget should be abolished as soon as possible. It has fulfilled its purpose, hospital staffing levels have increased, and care costs have risen from €14.6 billion in 2020 to €22 billion in 2024.

The hospital rating report takes a purely business-oriented approach. Regarding the overall increase in the number of full-time employees in hospitals between 2019 and 2023, and the low caseload in contrast, it states that productivity has "declined significantly." The number of nursing staff has even increased by 13.5 percent in the five years, the current report states. The category of productivity, for example, is at least questionable from the patient perspective, as well as from the perspective of medicine and nursing science.

The term suggests that hospital cases are standardized. This can only be true to a limited extent, if at all. A heart attack isn't just a heart attack for everyone. The older patients are, the more comorbidities they have, such as diabetes, kidney disease, or dementia. The medical and nursing care requirements can therefore vary greatly, which is reflected in the case mix category. This captures the varying severity of cases within the flat-rate reimbursement system.

However, the current hospital reform aims to weaken the mechanism of flat-rate payments per case and replace it with flat-rate payments per reserve. So far, however , the attempt has been half-hearted because the flat-rate payments are based on previous case numbers .

In addition, a certain staffing level has been set for the new service groups that hospitals will soon be billing for. The focus here is still on specialists, who must be available daily for the service group to be reimbursed at all.

If the flat-rate fees are indeed intended to lose their influence, it's questionable why nursing costs should be reflected again within this failed system. And it remains unclear how nursing costs can be prevented from being used again to alleviate hospitals' financial problems.

Many critics see the only way to prevent this is to establish realistic staffing levels as a basis for determining nursing effort. Hospitals will be faced with reconciling these different regulations in the coming years. Their interest, as the German Hospital Association has repeatedly stated, is to deploy nursing staff internally as much as possible according to their own ideas – without monitoring compliance with staffing ratios and similar requirements.

Not only does this contradict the interests of the employees, but patients certainly don't want to be cared for by highly flexible specialists who are shuffled around between wards like chess pieces and who are unable to deepen or even acquire specialized knowledge under such circumstances.

Criticism of plans to abolish the budget comes from, among others, the German Nursing Council. The increase in nursing spending is not a mistake, "but rather a reflection of decades of postponed adjustment," says Nursing Council President Christine Vogler. "Fair wages and more staff are not a luxury," they are necessary to make nursing professions attractive and ensure care, says Vogler. If there are problems in complying with minimum staffing standards despite the budget, the reason for this is, among other things, the lack of qualified personnel on the labor market.

Previous attempts to generate maximum output with as few staff as possible have led to a migration from the profession. Vogler calls this "care attrition." A 2024 survey of part-time care workers and those leaving the profession showed that, among other things, reliable working hours and needs-based staffing could encourage these workers to increase their working hours or return to work.

The Association of Democratic Doctors (VdÄÄ) also considers the abolition of the nursing budget to be fatal and proposes a radical countermovement instead: "A sensible step would be to finance all hospital staff according to the cost-coverage principle," says Peter Hoffmann, hospital physician and VdÄÄ board member. "That would be appropriate and would remove the cost pressure from staff. Furthermore, it would prevent profits from being made from staff."