Has the German health care system finally reached its limits because of the Covid pandemic? What challenges does it face? And how can digitization help us to serve people even better in the future? Three representatives of the Bosch Health Campus discuss tasks and solutions.
Schönthaler: In comparison with other countries – including industrial nations like the UK or the US – Germany is still looking very good. At no point during the pandemic was the German health care system seriously overwhelmed – which is not to say that it wasn’t very challenging for the doctors and nurses, many of whom had to go way beyond their limits. But the system per se stood the test – so far.
Alscher: The way I see it, right now we’re going through a crisis of the health care system. By international comparisons, it’s performing well – it proved itself in the pandemic too, as Dr. Schönthaler said. But we have a funding problem.
“We’re paying for Harrods and getting Woolworth’s. And that’s a problem.”
Straub: Yes, by international standards, we have the third most expensive health care system in the world. And in terms of delivery – that is to say, the health of the population – we’re not even in the top dozen. To put it bluntly: We’re paying for Harrods and getting Woolworth’s. And that’s a problem.
Straub: Health care in Germany is characterized by a strict breakdown into sectors, something that stands in the way of holistic change: There’s outpatient care, the hospital sector, and inpatient rehab facilities. Added to that is a fundamental separation into care and medical treatment, and not least the differentiation between medical specialties. All that has a role to play, but in the worst case it can lead to a silo mentality. Indeed, it prevents both patient-focused development of the system and innovations in medical technology, which have no regard for these sectoral boundaries.
Straub: Let’s take the example of care. Being looked after by a nurse can be medically relevant before the person drifts into a hospital situation in the first place. It would be conceivable, for instance, that already in primary care environments, staff would maintain close contact, record health information, make referrals to medical services, and spot potential ill health early on. Older and chronically ill patients in particular would benefit enormously from a more accessible system like that.
Straub: In demographical terms, it’s been a long time since we’ve had a population pyramid. It’s more of an onion shape – or even at some point a cocktail glass. This puts more pressure on the need for a health care system geared toward the treatment of chronic diseases – and the same is true for the topic of multimorbidity in older sections of the population.
Alscher: The subjects of prevention and diagnostics are becoming more and more important. Genetic data, for example, will help determine what predispositions a patient has, and then preventive measures and the relevant checkups can go a long way toward counteracting them. Our goal has to be growing older as healthily as possible. Health is the primary factor when it comes to quality of life.
Schönthaler: Of course it’s hard to predict where the greatest impact will come from, but there are a number of things we can identify already. The high global mobility makes it difficult or even impossible to curb the spread of diseases. We saw that with COVID-19. Migration will have an increasing impact on the development of diseases, because it has the effect of mobilizing the viruses.
Alscher: I have to agree. All of a sudden in Germany we’re again seeing disease patterns that we haven’t seen in the past or that we thought we had seen the back of. Like diphtheria, which is now reaching us again from Eastern Europe. Or heart conditions from inflammatory changes to the heart valves or multidrug-resistant germs. But of course migration also brings with it a great many opportunities. The influx of large numbers of people could be an answer to the skills shortage in health care. It’s a challenge, because this is a very sensitive area both culturally and in terms of language. It will come down to the quality of training and also how the day-to-day care situation is specifically organized.
Alscher: In the industrialized countries we are currently seeing that primary care is no longer working, for example that people are no longer being treated adequately in their own homes. That’s a huge problem. On the other hand, we have many countries which don’t even have any meaningful, good-quality medical care. At the same time we’re witnessing platform providers in particular breaking into the health arena in a big way – for instance Apple with its smartwatch, which can measure your heart rate, oxygen saturation and other data, which it uses to provide health tips. And of course simple things that your family doctor does can be taken over by algorithms. I’m thinking of sensors for blood pressure monitoring or blood glucose regulation. I can measure all these things via smartphone and provide them myself. The fascinating question will be whether these simple family-doctor activities will be developed commercially by Internet giants or whether the conventional health care system will manage to offer solutions here.
“As I see it, the biggest disruptor in terms of digitalization is diagnostics.”
Straub: We’re going to see incredible progress here in the next few years. Not just in the field of sensors, which Prof. Alscher has just mentioned. There’s another field that will bring with it very tangible benefits, not only for the patients but also for the efficiency of the entire system. Let’s take the example of patient data. A lot of examinations are being carried out multiple times. If the patient has all their medical data available and can easily take it with them from one specialist to another, that would be a massive step forward.
Schönthaler: As I see it, the biggest disruptor in terms of digitalization is diagnostics. Artificial intelligence (AI) will enable us to efficiently process enormous quantities of data, such as in imaging. It won’t be long before we can draw on reference cases to optimize treatment. However, I can also see developments which will lead to some difficult decisions. Very soon, the possibility of personalized risk assessments based on our genome will be greatly improved. But of course this also brings with it new responsibility. What do people do with the information that they are x percent likely to develop certain diseases? So we will have to learn to manage the information that AI makes available to us.
“As one of the central elements of the Bosch Health Campus, the Robert Bosch Hospital has the distinction of being a research hospital.”
Alscher: As one of the central elements of the Bosch Health Campus, the Robert Bosch Hospital has the distinction of being a research hospital. That’s what the founder wanted. He decreed that it should employ all possible means for recovery, even unconventional ones. That mindset sets the tone to this day. And what’s also key is that we are very fortunate to have, in Robert Bosch GmbH, a partner by our side who is at the cutting edge when it comes to health technology and digitalization.
Straub: The Bosch Health Campus is neither simply a research institution or teaching facility or funding body, but combines all these things to synergistic effect. For instance, we can approve funding for studies very quickly and without red tape. University institutions have a different setup, they’re perhaps not as agile, because they have academic decision-making structures. Take the interaction between the Robert Bosch Stiftung as the owner, and the hospital or the Bosch Health Campus. We regularly exchange information on various boards. And when we provide budgets for research, we can release the funds very quickly. Which doesn’t mean that we don’t assess or evaluate, but we don’t have to wait for long-drawn-out processes before we can make decisions. We can start working and researching quickly and, if necessary, adjust the direction as we go along. You can massively accelerate processes that way. Another important point is that we at the Bosch Health Campus have the possibility of trying things out in intersectoral models. So we can offer a showcase, which demonstrates what an optimum patient journey could look like – from a digital, medical, and technical point of view. This allows us to have an international impact too.
On the new campus, different facilities interlock in the best possible way - for the benefit of the patients.
Schönthaler: Translation is a good one, I think – meaning the rapid and direct transfer of research into treatment. On the face of it, medical research often appears to be a slow business and that’s because, initially, they work with classic models, like animal testing, for example, and these results then have to be transferred to people in a very long-winded process. All that’s important, there’s no argument. But we have – in our collaboration with the Robert Bosch Hospital and supported by the Robert Bosch Stiftung – the opportunity to work with patient material, and of course this allows very specific treatment options to be derived much more quickly. We have patients whom we can offer the chance to take part in studies, but who are also interested in research and are happy to play a part. So with this integration, we can dramatically shorten the translation route.
Bringing together individual departments in one place enables modern interdisciplinary treatment of patients - at university level and also for complex clinical pictures. The close integration of treatment and medical research is ideal for bringing the results of cutting-edge research quickly and directly into healthcare. Thanks to the campus's own education center, specialists can receive targeted training and continuing education. The integrated support area – the Robert Bosch Center for Innovative Health – turns the campus into a living lab; an experimental field for ideas on what better healthcare could look like. As an independent, nonprofit entity, the Center also conducts projects with external partners and supports third-party projects. Fast and agile action is a decisive criterion for success in these disruptive times. The Bosch Health Campus offers all the prerequisites for this.
Straub: Let’s take the megatrends we spoke about before: an aging society, migration, climate change, but also digitalization. If you take all these things together, then you automatically realize that separate, silo-based training always relies on these silo interfaces functioning ideally and therefore the people who operate there also working well together. But unfortunately that isn’t always the case. In contrast, a trans-sectoral and integrated approach to training, such as we are promoting at the Bosch Health Campus, is beneficial, because then you can organize the training and development in teams and based on specific cases. This is an option that the Bosch Health Campus is ideally placed to offer, because we see learning there as an integral component of research and treatment. Doctors and nurses follow separate training paths and only come together for the first time at the sickbed. It would be better to merge these two separate training pathways more closely. It specifically helps the patients, for instance, if the nursing staff too can recognize symptoms early on, in other words when there is continuity of care and treatment. This requires consistent interaction – and that’s what we institutionalize. We want to put people center stage. That’s something medicine has to aspire to in general.
Schönthaler: We want a healthy person. A person who gets the help they need quickly when they fall ill. It would be ideal, for example, if we could spot a tumor very early on, even before we get to the imaging. That’s something they’re specifically working on. Or alternatively, empowering the body to beat cancer by itself. In other words, the patients would get an injection and go home – before having to undergo an operation. That’s still a long way off, but in ten years’ time we’ll be a great deal further on. And with the Bosch Health Campus we can make a major contribution to this.
Alscher: What Dr. Schönthaler is describing is of course the ideal scenario. But even then we will still get severe cases and that’s when we need a phased system, which enables someone to get the best possible treatment in acute cases. As a research hospital, we see ourselves as having a special responsibility here. At the Robert Bosch Hospital, we’re developing or enhancing therapies which will tangibly benefit patients in the near future.
Straub: And we need an efficient health care system that finally crosses sectoral boundaries, first and foremost the strict division into inpatient treatment, outpatient treatment, rehab, and care. The Bosch Health Campus can be viewed as a successful case study here. But one thing we mustn’t forget: The best treatment is one which is not necessary. That also has to do with the subject of wellbeing. We have to empower people to look after their own health. This applies to a great many areas our Foundation is working on: How do we get to grips with inequality? How do we ensure optimal educational requirements? We view the subject of health as a nexus, where all relevant societal developments converge. That’s why we at the Bosch Health Campus must pull out all the stops in this area.