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EF: You have been reelected for another five years as head of the Berlin Hospital Association, indicating you are doing things right. What are your biggest achievements and mission for the next period?

MS: One of the achievements is that we have repositioned the Berlin Hospital Federation as a relevant actor in the healthcare sector. Despite the Covid pandemic's challenges over the last three years, we have proved we are crisis managers, guiding hospitals and problem-solving, helping us shape our profile back to its original level. We serve the public by providing information; we have an audience in all relevant media where we deliver factual information to the people of Berlin and all interested parties. Besides crisis management, we raise funding for hospitals; in Germany, hospitals have a legal claim to grants from the regional governments for investment funding. How much funding is granted is a political decision, and over the five years I have been CEO, we have organized three demonstrations gathering several thousand people demanding for rights and claims of the hospitals. Hospitals are now partners at a regional level, providing many activities. We have also created campaigns. Three years ago, our first campaign was for more nurses and more and better care in the city. Based on a scientific study of 2019 on the healthcare workforce till 2030, only in Berlin are ten thousand full-time working nurses needed. We have created a master plan to match this need. We employed extra staff to run this campaign and develop full public awareness through media: websites, blogs, and podcasts. We are starting another campaign for climate protection in and by hospitals. We know hospitals are big resource consumers; they work around the clock, and the carbon emissions are enormous -5% of CO2 emission in Germany is related to hospital activity. Working with German experts, we again created a master plan and raised funds with the regional government for the first million euros to analyze Berlin hospitals concerning the consumption of resources and emissions before deciding how to move forward. We are setting our agenda with relevant topics other than acting and reacting in crisis and politics. We have persuaded the government and the administration to go along with our climate strategy. The Berlin administration is employing extra staff and investing an initial 30 million euros in creating a hospital's climate protection cover capacity.  

EF: What are the main strategic points you want to focus on next?

MS: I already mentioned two of our priorities, the campaign for workforce and nurses and climate protection in and by hospitals. We will soon be dealing with more climate change-associated illnesses, what with globalization, Covid, and even tropical diseases in Europe, which will change the need for medical treatment in hospitals. More severe conditions will arise, particularly in big cities, because of air ventilation. In the summertime, with 35ºC, a heat-reaction plan is necessary. We have already started creating a plan for this, e.g. guiding hospitals on how to cool down patients' rooms.  

A third big topic is the digitalization of German hospitals, which are not among the best-digitalized institutions. We need to invest. We have a big investment package of 4.3 billion euros, co-financed by the national government and the federal states; this means some 220 million euros for Berlin, specifically for digitalization measures. We are now investing this booster in new devices and processes. We aim to make the investment sustainable in the permanent renewal of hardware and software, the renewal of licenses, and necessary purchasing to maintain the higher complexity of the digitalization level. We have a great challenge ahead; without IT specialists, a hospital can come to a standstill. As a hospital association, we must ensure that hospitals have access to skilled IT workers. I am proud that the Berlin Hospital Association can offer, in collaboration with a university in Berlin, an IT course specialized in hospital work with a curriculum that encompasses hospital management needs and IT. We hopefully will launch the course next year and have new specialists after a few years. Finally, working with the Chambers of Commerce, we are implementing special education programs for IT administration workers, looking at special education for the needs of hospitals.  

Then there are issues such as inflation costs; we are battling inflation of about 8%, and the hospitals do not have a flexible remuneration system; we have only been allowed a cost raise of 4.3%. The gap between cost and the increase is getting bigger, and this is just a symptom of the structural underfinancing of the hospital's running costs. The German DRG system no longer covers all the costs, endangering our healthcare system. The German hospital remuneration system has two pillars, i) the financing of the running costs done by the DRG system and ii) the investment costs borne by the regional governments. But the regional governments do not invest, and year by year, we are missing 3 billion euros which should have been invested but which we have not gotten. The underfinancing of the running and investment costs has led to the conviction we need a reform. The federal minister presented an expert committee report at the beginning of the process on the reform, which would endanger the very existence of hospital care if implemented as suggested. In Berlin, of our 60 hospitals, only seven would remain. Of the 22500 hospital beds we have today, only 7000 would remain. The committee believes hospitals should be organized in a new way, with five levels of hospital care. Each of the suggested five hospital levels would have to fulfill a certain structural quality criterion. They created 128 service groups, each including similar treatments – e.g., one group for orthopedics for extremities, another group for birth, and so on. Each group would be sorted into one of the five levels. Childbirth, for instance, would only be provided at level 2 or 3 hospitals. Level 2 must have a stroke unit, and half the hospitals in Berlin are not level 2, so they will not be able to deliver babies because they do not have a stroke unit. A stroke unit and birth have no medical connection, but this reform will mean that a hospital that delivers 4500 babies a year cannot go on doing so because they do not have a stroke unit. It is only one example of the many incongruences, and we have already proved it would not be implementable in day-to-day practices. We have also delivered our view and strategy for modernizing the hospital landscape. We agree that not all hospitals could be protected and that there must be a concentration process according to the region. We have big federal states with a low and even shrinking population density, but Berlin is a growing city of almost 4 million people, which shows the diversity of the starting scenarios in the different federal states. Since the reunification of Germany, we have had a vast reduction of beds in Berlin, and there is a low density of hospitals regarding population. The Berlin hospitals have a very high rate of use and a high case mix, a very different scene from rural areas; the national government analysis does not consider the various settings. We believe the German hospitals are more qualified to deliver a concept on the reform. The expert committee also gave a report on emergency care, which I do not think will be treated this year because we are at odds with the first hospital report.  

EF: You are also the chair of the committee of the EU international affairs in the DKG, giving you knowledge on how hospitals in the EU perform. How do you rate the performance at a regional level compared to Berlin?

MS: The problems described, digitalization, climate change, and lack of healthcare workforce, are all issues we have in common. The common challenge is better working conditions. Many domestic issues also exist. In 2010, there was the PIP scandal in Paris, where a French company used industrial silicon instead of medicinal silicon for breast implants, with thousands of women suffering pain and having to be re-operated. The EU immediately reacted to the scandal by launching a legal proposal in 2011; however, it took till 2017 for the EU lawmakers to agree on medical device regulation. Even today, we struggle with implementing this regulation. In the middle, we went through Brexit; traditionally, Great Britain has been among the notified bodies making the admissions for the new medical devices, which they no longer can do as they are out of the EU. The remaining EU-notified bodies had to be recertified as their quality was doubtful; all this has led to today not having the adequate number of notified bodies to admit new medical products. We still don't have any notified bodies for the so-called single-use devices, so other remaining notified bodies must newly admit the products that have been successful on the market for years.

We don't have adequate capacities, and companies are stopping to readmitting them or are not innovating, affecting the European population even to the extent of death due to the lack of an admittance process by EU law. Children are dying, especially when small product lines are not interesting for the companies under the new admission process. Doctors in hospitals must use medical devices developed for adults and adapt them to children's needs, with all the liability questions this implies. Fortunately, we are in dialogue with the Parliament, Commission, and Council with a new draft to postpone the implementation period for another five years, which should help. During the crisis, Europe raised much political awareness on medical devices with knowledge from third regions, such as Asia, to redirect production to the EU. But the medical device producers look for the best conditions for manufacturing, and labor costs in Europe are much higher, so it will be difficult to bring them back.  

We are in the last year of the legislative period on EU level, there will be new elections in 2024, and at the end of this year, the election campaign will begin, so the EU work will decrease, making it even slower than it usually is. We have missed chances to pass necessary laws, and working there is currently very frustrating.

EF: On a more positive note, could you share some successes in hospitals on strategic approaches to climate change or any other topic in Berlin?

MS: We have several very advanced hospitals in Berlin. They have decided to protect the climate and achieve carbon emission freedom and are on the way to their goal. The person who leads the climate protection groups in our member hospitals are part of our expert group that developed our strategic paper, which includes making a building more energy efficient hospitals have their heating system making the renewal energy plan expensive. Climate protection changes for buildings are a direct challenge to the extensive laws for monument conservation. People have romantic ideas about historic buildings, but we need to restore the Berlin hospitals, many of which are historic buildings. In some cases, we need to be allowed to neglect monument conservation to achieve climate protection. Our hospitals are investing in solar energy and reorganizing their food system so that it comes from certain regions. Beside Martin-Luther-Hospital and the hospitals Havelhohe, being the first climate friendly hospitals in Berlin, others are also working hard on their strategies; the Unfallkrankenhaus managed to employ well-known experts on hospital climate protection and launched new expert-driven processes. The Charité Facility Management, a daughter company of Charité, has a CEO who has already established several effective and successful projects for climate protection, some very simple, for instance, avoiding single-use cups and plates in cafeterias. In Berlin, now there is a trend in these strategies. Since 15 years ago, Martin Luther Krankenhaus has done much toward climate protection.

The mobility concept of the hospital is also important; in our strategic plan, the fleet of cars should be sustainable, and the mobility of 55 thousand employees coming to work daily is considered. It could be an additional idea to offer the employees electric supported bicycles, or to offer easier access to public transport means, to Installing electric filling stations in front of hospitals to promote the use of bicycles an electric car. We are also talking about waste management; the medical device industry did a study on their footprint waste. When they hand the medical product to the hospital, we must avoid waste; when it is unavoidable, we study how to better deal with it. Water consumption is another consideration: how water waste is redirected in the public water system. Also, recycling narcotic gazers that are emitting a lot of CO2s can be reused after preparation -good examples already exist also in Berlin. Every hospital employee can achieve low hurdle measures in a normal working day. We can save energy and resources, avoid wasteful consumption, lower our emissions, and share these good energy-saving examples with other hospitals in other federal states; we can all learn from each other. With the explosion of energy costs entering winter last year due to the war against Ukraine, we organized conferences. We invited experts to explain simple ways to save energy in hospitals that require special conditions. It was successful; we quickly achieved a reduction in energy consumption. There is still potential to be worked on in processes.  

Climate protection by hospitals must be a success. Having a hospital association that structurally works on strategic matters is critical. We do a lot of networking, basically organizing the money, talking to the government, and generally concentrating on climate protection. It is possible to create a hub on climate protection in Berlin. We are not an exclusive club; we are open and welcome colleagues in other federal states to make a good environment for this topic to flourish.

April 2023