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OPINION AND ANALYSIS

OPINION: Is Germany really the sick man of Europe?

Is Germany's economy really going down the drain, or is the country falling victim to a self-fulfilling prophesy that can still be reversed? There's reason to hope for the latter, writes Brian Melican.

construction workers
Construction workers in Kiel on August 31st. Photo: picture alliance/dpa | Axel Heimken

For those of us who have a rapidly-approaching rendezvous with the Big 4-0, 2023 is proving to be a soothingly nostalgic year. Summer has been a pre-climate-change style wash-out, girls are back wearing crop-tops and cargoes like Britney Spears in her heyday, and – with social-media fatigue widespread – it’s once again socially acceptable to send text messages and not care about the latest hashtag-driven campaign.

It’s like being in my late teens again, but with less acne and more money. Hell, even the news is like it was 20 years ago: according to The Economist, Germany is, a quarter of a century on from the paper’s original use of the metaphor, once again ‘The Sick Man of Europe’ and Deutschlandfunk’s morning programme is now more or less entirely devoted to how German industry, once the pride of the nation, is going down the pan.

If you’re younger than me, yet still have a distinct sense of déjà-vu, that’s because there is also a shorter cycle of repetition in play: for the third time in three years, German public discourse is suffering a nervous breakdown. First, it was Covid that drove us round the bend; then the Ukraine War had us terrified; now, we’re obsessing about the state of the economy

Carmakers like VW are part of the core of Germany’s industry. Photo: Yann Schreiber / AFP

Don’t get me wrong: all of these crises were (Covid) or still are (Ukraine and economy) serious. Yet the famed German angst and our national tendency to doom-spiral thought patterns mean that they seem even worse here – and, more worryingly, that we are, as a polity, in danger of becoming too depressed to take action.

This is especially difficult because, with the economy, we are facing a crisis mainly of our own making – and so one that only we can solve. Covid was force majeure and knocked everyone for six; the Russian assault on the Ukraine is one we played an unfortunate role in enabling and for which we were ill-prepared, but which has wreaked havoc globally.

Economically, however, we spent the 2010s singularly failing to ready ourselves for the future and so are now watching as countries with a lower reliance on legacy fossil-fuelled business models and better digital infrastructure pull ahead: not just the US, but France, Spain, and even Italy are outpacing us. The only other Western country facing the same stagnation is post-Brexit Britain.

Economists can describe in great detail why Germany will find it difficult to up output over the next few years, but essentially, it’s a lack of three things and an excess of one. Since the introduction of the famed Schuldenbremse (the ‘debt-brake’ to prevent excessive government borrowing) in 2009, there has been a chronic lack of state investment in basic infrastructure – witness the collapsing rail network and crumbling autobahns.

Meanwhile, as Germany’s population ages and the remaining workforce goes part-time, we are facing an increasing lack of labour. Immigration, once thought the magic bullet, has done little to change this because highly-qualified newcomers often leave again after a few years and our track-record in integrating low-skilled migrants into the economy is patchy at best.

Now, these twin chronic issues have been joined by an acute lack of energy as Russian gas has disappeared, replacement supplies have proven pricey, and we – in an act of national lunacy – have turned off our three remaining nuclear power plants. The one thing that Germany has an excess of, meanwhile, is generally considered bad for growth: red tape.

Ausländerbehörde Berlin

The entrance to the Foreigner’s Office (Ausländerbehörde), which has become a symbol of red tape in Germany – in Berlin. Photo: picture alliance / Kay Nietfeld/dpa | Kay Nietfeld

Yet none of these issues is exclusive to Germany. Years of insufficient investment infrastructure? Ireland’s rail and road network is incomplete and, in places, painfully slow, yet the Celtic Tiger has reawakened. Shrinking population? Spain is growing at 2 percent annually despite worse demographics than ours. Expensive energy? Austria has been just as badly hit and isn’t in a national funk.

Part of our issue is that, as a country, our expectations are sky-high. Germany is never content with being just another well-off Western country muddling through: we always have to be the World’s Best, and whether the discipline is industry, healthcare, or football, when we find out we aren’t, we lose heart – and lose the ability to see what we still have going for us.

As such, we now have the executives of major German industrials writing off the country behind their success to date and threatening to take investment elsewhere. And indeed, if they buy into the idea that we as a country are finished and do stop investing here, then we really will be in trouble. It’s a self-fulfilling prophecy.

So what is to be done? Germany beat its turn-of-the-millennium blues with an ambitious programme of reforms called Agenda 2010, and there are now calls for an Agenda 2030.

I agree that something eye-catching of the sort is needed to restore business confidence and show we are serious, but without the social welfare carnage unleashed back then which created an underclass for the sake of balancing the books.

In fact, quite to the contrary, Germany needs to invest, both in its infrastructure and its people. Last Wednesday’s government announcement contains a raft of measures headed in this direction, yet much of the package is actually just existing policy now clumsily comm-sed as the “Growth potential act” and “Future financing” acts.

No, we need a bigger bang. Here are three things I’d do. To invest sufficiently without resorting to short-sighted borrow-and-spend, I think we should, first, axe the billions of subsidies we lavish every year on dinosaur diesel vehicles.

We could then, second, use the savings to fund measures which would increase our future economic capacity.

Thirdly, we should create a top-brass commission with a simple task: to sit down and read through Germany’s reams of laws, ordinances, and regulations, both at federal and state level, and ask themselves three simple questions: Do we actually understand what is written? Is it at odds with other provisions or even self-contradictory? And does it help us to streamline and decarbonise our economy? Anything which fails these tests should be reworked or binned.

We could call this trio Agenda 2030-3 or something equally catchy – or come up with something else. Whatever we do, though, we will need the same kind of ambition, appetite for change, and willingness to take a few calculated risks in the face of naysayers and status-quo lobbyists that we showed in the early 2000s. As I said, in fashion terms at least, those years are currently experiencing a revival…

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OPINION AND ANALYSIS

OPINION: Why it’s becoming harder to get a doctor’s appointment in Germany

Germany's health service is known as one of the best in the world but securing a timely appointment with a doctor is getting harder. A creaking system and the culture around excessive doctor visits are part of the problem, argues Brian Melican.

OPINION: Why it's becoming harder to get a doctor's appointment in Germany

Germans have always been known for being health-conscious – some would even say hypochondriacs. That has its down-sides (see Covid…), but also some notable advantages. One is the ability to go to any doctor’s practice and request treatment, skipping general practitioners, referrals, and all of the attendant bother.

As a result, in any well-to-do area of a major German city, you’ll have a bewildering array of medical practitioners within walking distance, from general physicians (Allgemeinmedizin) and orthopaedic practices (Orthopädie) to ones that will have you Googling (HNO stands for Hals-Nase-Ohren – ears, nose, and throat – by the way. You’re welcome.)

The strength of this patient-choice system is that it allows people to manage their own care. So if one doctor can’t see you, you go and find another. And if you’ve moved towns or fall ill away from home, you can still access care. In theory, this spreads demand and keeps people with non-urgent complaints out of casualty wards. Yet in practice, the system is now creaking audibly. 

In recent months, I’ve tried to get appointments for several routine procedures with doctors’ offices I have been visiting for years – and the earliest I could get anything was, to my surprise, now several months off. Both dentists and dermatologists are currently, it would seem, planning their schedules for September and October. And when a rather unpleasant case of shoulder pain struck earlier this year (fittingly, just ahead of my 39th birthday…), the earliest appointment I could get at any of the three(!) local orthopaedic practices was at least a month off.

This isn’t just me getting unlucky here. In a recent representative survey, only 25 percent of respondents reported having no trouble getting a doctor’s appointment. The rest are having to wait anything between two weeks and two months – and I’m clearly now one of the 15 percent who report even longer delays. 

I’m not alone in thinking – knowing – that it didn’t used to be this way. So what has gone wrong? 

READ ALSO: Seven things to know about visiting a doctor in Germany

Structural changes in medical practice: fewer doctors working fewer hours

First off, there are changes afoot among Germany’s niedergelassene Ärzte – literally ‘settled doctors’ with surgeries, called so in order to distinguish them from hospital medics. For one, these doctors are getting old and retiring – just like the population they serve (or rather: have served). And as younger cohorts are less numerous, physicians looking to pass on their practices are having difficulty finding takers – especially in disadvantaged urban areas or out in the sticks.

A patient undergoes a consultation with his doctor.

A patient undergoes a consultation with his doctor. Photo: picture alliance/dpa/AbbVie Deutschland GmbH & Co. KG | AbbVie Deutschland GmbH & Co. KG

Even where there is no shortage of potential successors, ever fewer of them actually want to set up in business for themselves. For most young medics’ taste, there’s too much paperwork, too much commercial risk, and far too much work involved in running their own surgery. Instead, they prefer to merge with others or sell on to management companies who will, in turn, employ them (often part-time, with no annoying evenings or weekends on call). 

The results of all of this are as follows. Within the space of just one year, between 2022 and 2023, the number of surgeries fell by 1,987 – a drop of over two percent. Meanwhile, in 2023, for the first time ever, more than one third of Germany’s 150,000 non-hospital doctors were employees, not self-employed. That’s twice the number in 2013. Moreover, over the same period, the number of medics opting to go part-time has gone up by 235 percent to 60,000. This means that, if your local surgeries haven’t closed, the likelihood is that the doctors there are now working fewer hours – and so there are fewer appointments left to go round.

READ ALSO: Do doctors in Germany have too little time for their patients?

This would be bad news for any society, but it hits particularly hard in Germany. As a rapidly-ageing society with a relatively unhealthy population (high rates of smoking and obesity), our demand for medical services – often for complex chronic illnesses – is rising just as provision is declining.

Cultural differences in consulting doctors

Another problem is that Germans are accustomed to a historically high number of available doctors – and as serial worriers (and passionate sick-note seekers) make excessive use of them. Your average German racks up almost 10 consultations a year – not including visits to the dentists! The OECD average is closer to six. And the stoic Swedes, strong silent types that they are, go the doctor’s just 2.3 times a year.

Even if I wanted (or needed) to, I simply couldn’t to get to the quack’s almost once a month: I don’t have the time and they don’t have the appointments. But in conversation, I notice that others clearly do manage to find both. Increasingly, I’m wondering how many of them, unlike me, have private health insurance. 

This brings us to the third major issue facing non-hospital care in Germany. When the figures in the representative survey I quoted above are broken down, it transpires that almost 60 percent of people who are insured in the state system (gesetzlich versichert) are now waiting longer than two weeks for an appointment; among those who are privately insured (privat versichert), that figure is only 37 percent.

Doctors ‘keen on private patients’ 

Doctors are keen on private patients because their insurers pay more for the same procedures and will also cover all sorts of supplementary stuff – from the clinically-proven through to the just plain wacky. As such, practices reserve as many appointments as possible for private patients and try to keep the rest of us at bay.

Given that around four in five people in Germany are in the state system, however, this leaves the majority of patients competing for the minority of slots. If you want to see how the other fifth live, try “accidentally” clicking privat on surgeries’ online booking tools: you will now see a range of appointments available within days while the rest of us are being fobbed off for weeks or even months.

Not only is this, as my grandmother used to say, enough to make you want to join the Communist Party – it’s wildly inefficient. By restricting the hoi-polloi to slots often months off, doctors are creating their own appointment-management problems: sometimes, the complaint in question will have disappeared by the time the consultation rolls around; more often, it will have actually been dealt with – not infrequently by the same physician – if the patient presents as an acute case earlier.

As such, slots weeks away are booked, only to be cancelled later by conscientious patients (and left blocked by others), while those same patients crowd into waiting rooms begging to be seen urgently at an open surgery. (That’s how I got my shoulder looked at.)

A German health insurance card.

A German health insurance card. Photo: picture alliance/dpa | Jens Kalaene

The cynic in me says that, in the long run, this might not be such a bad thing. If the increasing scarcity of doctor’s appointments gets Germans thinking about whether they really, really need to be seen for yet another case of the common cold (“No, Christian, it isn’t pneumonia this time, either!”) or various nebulous self-diagnosed ills (Kreislaufbeschwerden (circulatory problems) is the day-off-work-one I love to hate), maybe it’s not a bad thing.

Swedes don’t die unnecessarily because they avoid the doctor’s: in fact, they live a good year longer than us on average. The German in me, though, says: “My shoulder hurts. Maybe I’ve got early-onset arthritis. I should probably go and get it checked out…” And even though I don’t go too often, I’ve got used to being able to see a specialist when I need one. It’s a shame that this is becoming markedly more difficult.

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