Letter from Germany 9 – NHS

March 2019 saw me in my new home city in Central Germany and two years on I am living in a time of a pandemic.

I began writing these letters at the start of the pandemic in an attempt to understand Germany better and to get to grips with my relationship with the United Kingdom.

Covid Home – Letter OneLetter TwoLetter ThreeLetter FourLetter FiveLetter SixLetter SevenLetter Eight

Letter from Germany – March 12 2021.

It is now over one year since our lives were changed because of the Covid-19 and I´m not sure what´s tougher to deal with Covid isolation or the long winter.

As I sit here thinking about my ´Foreigner’ status in Germany and the forms etc., involved I have come to realise that my life in the United Kingdom was framed by the National Health Service (as part of the ´Welfare State´).

UK Post War Agenda – the NHS
This may seem a sweeping generalisation, but during World War Two Britain was a war winning quasi-Command Economy or as a quasi-Socialist as you could become before it’s Soviet. From this position UK society, once united in a joint enterprise encompassing very disparate groups of people subsequently digressed – notably the medical castration of Nazi code breaker hero Alan Turing, women sent back to their stereotype roles and the birth of the notion that Britain had done it alone and could retain its Imperial glow. Nonetheless it did see the introduction of the Welfare State as a Governmental exercise in connecting capitalism, democracy, and citizen welfare equitably.

Having won the war, the fight to win the post-WW2 peace had begun and this continues to this day. After World War One the idea of a National Health Service began to gain strength from the notion of building on the benefits of war time health provision, but it took until after WW2 for the Labour Party to make it happen in 1948 (See Southfields Cemetery – Let´s Create the NHS).

There was of course great resistance plus political noise and from its beginnings the Welfare State was undermined with the narrative that it was for the feckless; social housing was for losers etc.  – with this rhetoric has come annual Governmental cuts and an erosion of political purpose for the redistribution of wealth to a more level playing field that many felt they deserved after years of war. I recall my childhood living on a newly built council estate in Bristol with my ‘war winning’ parents and reading newspaper columns, or hearing ruling elites and ´taxpayers´ say that we were somehow lesser than homeowners and the like.

Despite what it said on the infamous bus during the referendum campaign (350m pounds a week for the NHS) the ideological thinking of many Leave leaders was that European Union Membership was a roadblock to their aspirations to see a neo-liberal revolution in the UK (minimum tax, free market, UK centric tariffs & minimum oversight etc.) and a rewriting of the post WW2 agenda which included the NHS. Presently these people have the ear of the government.

Whether the NHS is safe in the hands of the Johnson Government in the post hard-Brexit UK is very much up for debate and a recent acquisition of a UK general practice operator indicates interest in NHS assets from Big Pharma in the USA, a market that many Brexiteers are very keen to open the NHS to.

In Germany
Now, living in Germany, I see that my new home country, located adjacent to many neighbours (not an island) has allowed itself some ´sliding room´ by keeping Covid-19 down to ´controllable´ levels, but it was and still is a close-run thing and in December 2020 Germany´s Covid death total jumped from just above 13,000 to over 35,000 deaths (it now stands at 70,000+ from 2.45 million cases).

The biggest fear in Germany is that the extremely more infectious UK variant (and others) of the Covid-19 virus will run rampant across Continental European lands and there is disbelief that the UK allowed this variant to take hold and spread and thus endangered everyone. 98% of infections in the UK are now of the Kent variant and in some recent tests in Germany it was found that 40% of positive tests were of the same.

What the UK has in its favour is the NHS and despite all its issues including underfunding and calls for its demise, it has been the sole reason why the UK has weathered the pandemic thus far. Here in Germany, there is no national health service and patients are treated at private clinics or doctors’ practices (they are de-facto individual businesses).

The German health system is complex, but basically all must sign up to statutory health insurance, when you apply you basically enter into an negotiation with a public non-profit provider – if you earn below 64,000 Euros per annum you pay a basic figure (subject to means testing), if you are salaried you share this sum with your employer and should you wish you can opt to pay privately (the latter means better service). For German freelancers, the system is particularly tricky to navigate and expensive as there is no employer’s contribution.

In addition to personal and employers’ contributions the National Government contributes greatly to the health service and there are safety nets for the unemployed etc., and although it is one of the freest market health systems, costs are monitored, and caps set by a central body. Some doctors who are keen to maximise their cash flow will focus on money earning medical procedures.

The Germans spend just over 11% of their GDP on health whilst in the UK the figure is just above 7%.

A report published in Berlin a few years ago caused quite a furore in Germany when it suggested cutting the number of clinics (hospitals) stating that many replicated each other, and whilst some are centres of medical excellence others are not (old equipment). That there also existed a surplus of beds which cannot be sufficiently staffed heightened by cuts to enable health carers to meet their costs. This is not to say that the health care is less or better than the UK, because in general care in Germany is particularly good, but you might have to shop around.

Culture Shock
It is quite a culture shock for me when talking to health workers (doctor, dentist etc.) about one’s health care when the conversation turns to whether your insurance will cover it and if not, they will hand you an itemised list of costs (the use of a microscope for instance). Nonetheless it would be wrong to compare it with the USA model. Dentistry is not generally available on the NHS.

Fighting Covid
A great strength of German democracy is the devolved nature of government and there was no waiting on a Prime Minister´s words to take first steps to combat the virus and Germany did remarkably well until December/January when the winter surge hit (2nd wave). This devolution of power means that decisions must be reached by consensus between the National Government and Federal States and at times the players have not all been fully in agreement. Nonetheless the actions of local, regional, and national agencies etc. have held. In my home city of Göttingen the Covid-19 infection rate is hovering at about 30/40 people per 100,000 (the National rate is 64 per 100,000). The hope is that a combination of a low infection rate, keeping the variants at bay and vaccinations will see us good by the Autumn. We are importantly also obliged to wear medical masks when interacting with each other and I am entitled to not just free masks but also free self-tests (plus tests can be bought over the counter at supermarkets). In the UK 124,000 people have died and the rate is much reduced to 84 per 100,000 because of the success of the NHS vaccination programme – although there are wide regional variations (London is one place where delivery and take up has lagged because of supply issues and vaccine hesitancy).

Vaccines – FAX me
In Germany, the vaccines are procured and distributed by the National Government to the Federal States and the methodology of delivery and into arms is up to the individual states. The vaccination of the population of Germany has been hampered by having to create a system to deliver it without an NHS or an appropriate national data base, instead relying upon local ones. Amazingly the FAX machine is not dead in Germany and one criticism of Chancellor Merkel´s tenure is the lack of progress regarding digitalisation. Regularly I must renew my permission on a printed form for my doctor to access my personal data to treat me.  If I were to be admitted to a hospital in an emergency, I am unsure whether they would be able to readily check my medical record not only because of data protection matters but also because someone might be waiting for a FAX.

A shortage of vaccines caused by production issues is also playing a role in a sluggish roll out of vaccinations here in Germany. The country elected to join with all European Union members (other than the UK) by pooling their dealings with the suppliers of vaccines. This meant that these countries would not compete for product on price and delivery priority. Meanwhile the UK was celebrating Brexit (although then still technically a member) by saying that they had quicker access to the vaccines because of being liberated from the joint approach of the EU (the same when they previously OK´d the German BioNTech vaccine). This got rather silly when supplier AstraZeneca told the EU that they would not deliver the ´agreed´ doses as the EU had assumed. AstraZeneca suggested it was obliged to supply the UK first, but this was disingenuous, and it appeared to the EU they were giving preferential treatment to the UK Government. Whatever the rights or wrongs, this gave the impression that once again the UK Government of Boris Johnson was in some way duplicitous. At this time, no AstraZeneca vaccine has been exported from the UK to the EU.

Not that Vax
The irony is that in Germany people don´t want the AstraZeneca vaccine saying that it does not give them as much protection as other vaccines because people don´t want to catch Covid-19 at all, even if the vaccine prevents hospitalisation or deaths. There also exists doubt whether it is as good as the BioNTech or Moderna MRNA vaccines against the emerging variants. A major issue is that the German Government did not authorise its use until early March for people over 65 because of a previous lack of data. To add a wee bit of context, a recent survey in Germany claims that one third of Germans do not want to be vaccinated against Covid-19 in the first place. As I post this letter some countries are halting the use of the AstraZeneca vaccine because of reports of deaths caused by blood clots in recipients.

Of 300,000 doses available just 88,000 doses of the AstraZeneca vaccine had been taken up in Germany at the beginning of March, and the Government is urging Germans to accept it. Issues regarding the company not being forthcoming at first about their trial results, and the recent falling out with the EU have not helped.

In the UK I have seen a general welcoming of the announcement that from June 21 the nation may see the end of most Covid-19 restrictions thanks to the workers in the NHS. I do hope so but judging by the UK Government’s general record so far, I do have my worries.

What is clear to me is that the NHS is a thin line which prevented the UK slipping into a greater catastrophe, but after Covid it will be exhausted. Will it be able to meet the medical needs of people beyond Covid especially because although the UK people may have reengaged with the NHS like their 1948 brethren there is little to suggest that ideological antithesis against it has changed for a sizeable number of politicians (many in the government have a strong ambivalence to the NHS). The March 2021 Government budget included cuts to NHS spending and nurses etc., were given a 1% wage increase and this might be an indicator of things to come.

In Germany, most people remain behind the Covid restrictions although they want them to be lessened, and this is happening. But 50% are not happy with the vaccine programme roll out. Thankfully, Germany, as was the case during the early phases of the pandemic, can help other nations because its own infections are within ´manageable´ margins. The German military for instance opened a field hospital near Lisbon to help the Portuguese who were close to the point of being overwhelmed.

Pandemic – the end in sight?
Here in Germany, we are being warned that we could be at the start of a third wave of infections because of emerging variants of Covid-19 and thus no dates have been set for life as normal resuming. By contrast, in the UK I get the impression that June 21st is being built up as the end of the Covid-19 pandemic.

The German stumbling (not a disaster) vaccine approach will take longer, and the onus remains on lowering the infection rate and to snuff out variants at their source whilst re-opening gradually depending on local rates. The vaccines will thus allow herd immunity to be built in a stable Covid-19 environment. It is planned that there should be 100 million doses available per month in the EU from April and 20 million of which is for Germany.

Germany and others would be wise to embrace lessons from the NHS approach – whilst being national, the NHS is also very local in nature which helps with the logistics of the vaccine roll-out on the ground. At the same time, the NHS uses a very pragmatic approach; Germany should not just allow local Doctors but also very importantly NURSES etc., to administer vaccines in local settings (big and small) as is the case in the UK. Ultimately Germany will get the vaccines it needs, and it will get them into arms. Estimates suggest that the UK might achieve herd immunity in July 2021. Currently over 20 million people have received their first Covid vaccination in the UK and over a million their second. In Germany over 4 million have had one dose and over 2 million their second at the beginning of March. I believe that 60 million people need to be vaccinated in Germany to create herd immunity and if logistics or supply allow herd immunity in Germany should match the UK prognosis.

Not a metronome country
The Covid-19 pandemic is likely to change Germany and any notions that it is a metronome country run along stereotypical Teutonic/Nazi (as the British press like to assert) rigid lines is a nonsense, it´s one of the reasons I feel I can live here. It is in general an open, imperfect society and it will move on. Economic forecast for instance suggests that the financial hit from Covid-19 for Germany will be less than the 2008 economic meltdown (my fingers are crossed) and Brexit fall out is not a high priority, although neither is it being ignored, but simply put into context in this time of Covid-19.

I hope that the NHS will not be exhausted and demoralised, or overburdened with huge waiting lists for cancer care etc., and that it will be rebuilt in the spirit of the 1948 ideal and not thought of merely as a commercial asset in the new Brexit free market UK economy.

Earlsfield Cemetery – Lets Create the NHS

P.SA taste of home

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