Can the NHS learn from Germany’s health system?


We love the NHS. We clapped for health workers and carers in the first wave of the pandemic. A large majority of us want to keep an NHS which is free at the point of use for all.

But public satisfaction with the service has fallen to its lowest since 1997, according to a recent British Social Attitudes survey, and increasing numbers are not happy with the standards of care provided.

Therese Coffey this week became the latest health secretary to pledge improvements for England, but are quick fixes possible, or is root-and-branch reform needed, and could other countries provide an answer?

Germany has a public health system, but one which is funded in a wholly different way. According to the Commonwealth Fund think tank, around 86% of the population there are enrolled in schemes run by not-for-profit insurance organisations known as sickness funds.

People can choose which fund they sign up to. These are paid for by deductions from wages with employee and employer contributions. Some small out-of-pocket payments are required for hospital visits and medicines.

The government has virtually no direct involvement in providing care. Higher-earning German citizens can opt out of the statutory insurance system and choose private health cover instead.

Funding of the two systems is similar. Germany spent just under 13% of its gross domestic product on health in 2021, according to preliminary figures from the Organisation for Economic Co-operation and Development (OECD). The equivalent figure for the UK was around 12%.

The most recent data for cancer survival rates dates back a few years, but they show more patients are alive five years after treatment in Germany than the UK. For cervical cancer the gap is small, and for colon cancer it is bigger.

The German system is better staffed and stocked than the UK, relative to the population. Analysis by Nuffield Trust shows in 2019 the UK had around nine nurses per 1,000 people, while in Germany there were about 14. The disparity in bed numbers was wider – with Germany’s eight beds per 1,000 patients more than three times higher than the UK figure.

Dr Kristian Niemietz, of the Institute of Economic Affairs, thinks it could be a blueprint for reform in the UK: “Social health insurance systems tend to have better healthcare outcomes.

“Patients enjoy a greater degree of individual choice and benefit from shorter waiting times. Switching to a social health insurance system would not be a panacea.

“But if we want to combine the best aspects of a public system with the best aspects of a consumer-focused market-driven system, social health insurance is a tried and tested way to do that.”

Could the UK follow suit?

Germany’s health model is widely admired. But would it work in practice in the UK?

There is no clear evidence that the system itself is the key factor in driving health outcomes. It could be that Germany, as a relatively rich country and with fewer inequalities, has a healthier population.


For the UK to switch to a German model would require a major structural upheaval, with a large bill attached.

A social insurance system might take some of the politics out of health and reduce the power of the Treasury to control funding.

But the British public might need some persuading that going back to the drawing board and starting again with a massive shake-up is worth the trouble.

Nigel Edwards, chief executive of Nuffield Trust, is sceptical: “Social health insurance is not a magic ingredient. A move to that kind of model, even if possible, would require additional resources. The NHS could not magic up the additional beds, staff and equipment to create the market needed to make social insurance work – these are not optional extras.”

Another think tank, the King’s Fund, has argued that properly designed social health insurance can provide comprehensive cover to all in a similar way to tax-funded systems, but it says administrative costs can be high.

There has been a history of under-spending on buildings and equipment for the NHS. Germany spent more than three times more per year as a share of GDP than the UK between 2015 and 2019.

Money is not the only answer: there is general agreement that the health service could be more efficient.

Ask any health leader in the UK what the main priority is and they will say workforce. The numbers of doctors, nurses and other health professionals have not kept pace with patient demand. Plans for training staff in previous years have proved insufficient. Vacancies are increasing

But here the NHS is not alone. The World Health Organisation has predicted a global shortfall of 15 million healthcare workers by 2030.

Developed economies are competing for overseas staff. German hospitals are as much in that market as the UK’s. For some applicants the NHS brand and model might have a particular appeal.

Nobody denies that the NHS could do better. Politicians and the public know that long ambulance delays and waits for planned operations are eroding confidence.

But the jury is very much out on whether copying a different country’s health system is really the way forward.


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