Substitution of prescribing rights in Germany

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

In the German health system only physicians have the right to prescribe medical treatment (?selbständige Ausübung von Heilkunde?). An amendment of the statutory long-term care insurance (?Pflegeweiterentwicklungsgesetz?) in 2008 obliged the Federal Joint Committee to produce a list of treatments which could be prescribed by non-physicians in future pilot projects. The deadline has expired, but the list has been announced for the year-end.This development reflects an important change of paradigm.

Purpose of health policy or idea

In 2007, the Advisory Council on the Assessment of Developments in the Health Care System ("Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen") highlighted the future shortage of health care providers. The Council recommended a reorganization of the health professions so that certain tasks could be carried out by non-physicians. For instance, certain tasks that are normally under a physician's responsibility could be provided by nurses or doctor's assistants. According to the Advisory Council there are four main possibilities to change professional roles.

1. Delegation refers to the assignment of tasks by one professional group to another. Essential is that the assignment could be withdrawn at any time. This is already practiced in some hospitals, where nurses have obtained more responsibilities such as taking blood samples.
2. The term substitution stands for giving the responsibility for a task in principle to other professional groups. This permission cannot be withdrawn. It leaves the option open whether the originally responsible professional group keeps the right to carry out this task or looses it.
3. Diversification means that new tasks are added to the ones normally associated with a certain profession.
4. Lastly, specialization implies that some members of one professional group specialize in certain tasks.

In Germany, there is an alleged shortage of physicians. A rearrangement of professional tasks could relieve doctors from some tasks. This has to be seen in the context of the organization of the German healthcare system, which is based on the physician's exclusive right to prescribe treatments and pharmaceuticals. Non-physicians are only allowed to provide treatments upon referral from a physician.

A substitution of the right to prescribe treatments in certain pilot projects is foreseen in the "Pflegeweiterentwicklungsgesetz". During the health policy process (see below) it turned out that as a compromise the Federal Joint Committee will draft a list indicating all treatments that may be prescribed by non-physicians in pilot projects. It is important to note that these prescriptions can also still be made by physicians. This ends the exclusive right of physicians to prescribe and is a significant change of paradigm in German health care, irrespective of what the list will look like in practice.

Before the idea to substitute prescribing rights was launched, a project named "AGnES" was conducted. This project studied the delegation -not the substitution- of house calls to especially qualified doctors' assistants using e-health-tools such as video conferencing. The result was convincing as more house calls could take place. Finally, the "Pflegeweiterentwicklungsgesetz" enabled the GPs to bill the house call provided by the doctors' assistants. As a result, delegation became part of standard care in regions with a shortage of GPs. This project strengthened the opinion of the physicians' professional organizations that delegation should be preferred to substitution.

According to the Advisory Council, non-physician professions will become more attractive, because they will be allowed to take more independent decisions in their professional life, their social status will increase and a continuous (academic) education will become possible. It is also believed that total labour costs would decrease because as most non-physicians take shorter training time than physicians     their income is lower.

Main points

Main objectives

•  To avoid health care provision shortfalls caused by an increasing shortage of staff (physicians and professional caregivers for seniors and the disabled)

• Relieve GP workload

Type of incentives

•  Better income and status for health professionals (non-physicians)

• Possibly less costs for insurers

Groups affected

Physicians, Other health care professionals (e.g. nurses, professional caregivers for seniors and disabled, physiotherapists), Patients

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Political and economic background

A reform of professional roles in health care is seen as instrument to face two main problems of the German healthcare systems. These include (1) the shortage of physicians and (2) the shortage of financial resources. The draft bill is closely related to the situation in outpatient long-term care. Long-term care has become an important issue in health care because of the changing age structure. The increasing number of elderly people causes an increasing need for long-term care for the chronically ill. Long-term care is provided by nurses and professional caregivers for seniors and the disabled. Until now, they need a prescription from a physician for every treatment, which had to be written, on average, every four weeks. This means more administrative work for both physicians and nurses, but to no additional advantage for patients. Furthermore, substitution of the right to prescribe might cut costs for wages in similar treatments because caregivers and nurses are paid less than physicians.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

Many western countries have already successfully strengthened the responsibilities of health workers like nurses and professional non-physician caregivers through various forms of substitution.

An example is nursing diagnosis in Sweden, a concept originally developed in the USA. The nurse decides whether or which further treatment is necessary. In the USA, emergency ward nurses determine the priority of patient treatments (triage).

Especially the prescribing right was given to non-physicians a couple of years ago in some countries, e.g. to "nurse practioners" in New Zealand and the Netherlands (see references below). Such tasks can only be assumed by adequately trained staff.

In many countries non-physician health professionals are educated in universities and are better prepared to assume more responsibility.

Initiators of idea/main actors

• Regierung: The law was adopted during the last election period. The Ministry on Health legally supervises the production of the list of treatments.

• Parlament: The parliamentary question of the Green Party pointed out the nonexistence of the awaited list.

• Leistungserbringer: Federal Association of Statutory Health Insurance Physicians is a full voting member of the Federal Joint Committee.

Approach of idea

The approach of the idea is described as:
new: Although the idea has already been implemented in many countries, the measure is a change of paradigm in the German health care system.

Stakeholder positions

In 2007, the Advisory Council for the Assessment of Developments in the Health Care System recommended that new forms of cooperation between health professions were necessary to guarantee sufficient health care provision in the future. The council recommended developing new and flexible health care professions.

Actors and positions

Regierung
Federal Government	sehr unterstützend		stark dagegen
Parlament
The Green Party	sehr unterstützend		stark dagegen
Leistungserbringer
Physicians' organizations	sehr unterstützend		stark dagegen
Non-physicians' organizations	sehr unterstützend		stark dagegen

Influences in policy making and legislation

The first draft bill of the "Pflegeweiterentwicklungsgesetz" was presented by the Federal Government in December 2007. The bill already contained the article No.6 which states that pilot projects could allow nurses and caregivers to prescribe any treatments, provided that professional skills and education are adequate. In a hearing of the Committee on Health of the German Bundestag in January 2008 it became clear that the positions of physicians and non-physicians differed fundamentally. Professional chambers of physicians were strictly opposed to any prescriptions written by non-physicians (substitution). Only the expansion of delegation was acceptable to them. Nursing, caregivers' and physiotherapists' organizations appreciated the proposal and referred to successful and existing practices e.g. in home long-term care. 

As a consequence of the hearing, the Committee on Health modified the draft. Two sentences were added to § 63(c) in the SGB V. The Federal Joint Committee was appointed with developing a list of tasks where non-physicians could make independent prescriptions as part of pilot projects. Deadline for this was the 1st of January 2010. This was meant to enhance the acceptability of the new substitution forms as an physicians' chamber (Federal Association of Statutory Health Insurance Physicians) is represented in the Federal Joint Committee. Although other (non-physician) professionals' organizations are not represented in the Federal Joint Committee, the committee is obliged by law to hear the statements of those organizations. 

Although the deadline for the presentation of the list has already expired, there are as yet no publications dealing with this list or on the Federal Joint Committee's activities.  On 1 April 2010, the Federal Government answered to a parliamentary question by the Green Party that the guideline will presumably be published in 2010. 

Legislative outcome

success

Actors and influence

Regierung
Federal Government	sehr groß		kein
Parlament
The Green Party	sehr groß		kein
Leistungserbringer
Physicians' organizations	sehr groß		kein
Non-physicians' organizations	sehr groß		kein

Positions and Influences at a glance

Expected outcome

In face of the aging society and health work force, as well as the shortage of physicians predominantly in Eastern Germany, it is appropriate and necessary to test new health care delivery models such as substitution of prescribing rights. The "Pflegeweiterentwicklungsgesetz" outlines that only nurses, caregivers and physiotherapists with sufficient training may take independent decisions. Provided that there is adequate training there is no reason to prevent non-physician health professionals from taking care decisions. 

The Federal Joint Committee's list of tasks can be seen as a compromise that will guarantee that not too many prescribing rights will be substituted because it is linked to present professional training status. Furthermore, the committee is not able to foresee future pilot projects. This means that future pilot projects will be restricted by the list and that for new experimental pilot projects the list might not provide sufficient options. In other words, this compromise may seriously hamper larger innovations - possibly already visible in the delayed presentation of the list. Nevertheless this is still a chance to relieve GPs in outpatient long-term care from (mostly administrative) routine services, such as prescriptions refills for the chronically ill. Wound management might be a medical treatment where professional caregivers and nurses could assume more prescribing responsibility.

When non-physicians are given more prescribing rights, the question of professional liability insurance and the freedom of establishment are raised automatically. Minor changes as currently proposed will probably not influence the choice to become a non-physician health worker; although it may be more attractive if there was a distinct field of responsibility. This is of course strongly connected to the education level. The reform of non-physician professional training, which was started under the previous minister of health Ulla Schmidt, still has a long way to go. Most developments can be seen in nursing education. The schools of nursing were and are affiliated directly to hospitals and organized as a typical German in-service (on the job) training. However, new opportunities to study nursing science at colleges of higher education ("Fachhochschulen") have emerged. This type of nurse training is still unattractive as long as wages for nurses are low, possibilities for higher pay are lacking and more career opportunities, including more responsibilities and competences, are missing.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

References

Sources of Information

Policypapers

• Deutscher Bundestag.Gutachten 2007 des Sachverständigenrates zur Begutachtung der Entwicklung im Gesundheitswesen. Kooperation und Verantwortung - Voraussetzungen einer zielorientierten Gesundheitsversorgung. http://dipbt.bundestag.de/dip21/btd/16/063/1606339.pdf
• Ausschuss für Gesundheit. Stellungnahmen zur öffentlichen Anhörung zum Entwurf eines Gesetzes zur strukturellen Weiterentwicklung der Pflegeversicherung (Pflege-Weiterentwicklungsgesetz) und weiteren Anträgen.http://webarchiv.bundestag.de/cgi/show.php?fileToLoad=1550&id=1134
• Deutscher Bundestag. Antwort der Bundesregierung auf die Kleine Anfrage der Abgeordneten Dr. Harald Terpe, Cornelia Behm, Elisabeth Scharfenberg, weiterer Abgeordneter und der Fraktion BÜNDNIS 90/ DIE GRÜNEN.http://dipbt.bundestag.de/dip21/btd/17/013/1701304.pdf

Further references

• Kerstin Blum. "Nurse practitioners in eastern Germany". Health Policy Monitor, October 2006. Available at http://www.hpm.org/survey/de/b8/3
• Han van Dijk. "Nurse Practitioner Curriculum". Health Policy Monitor, 6 May 2003. Available at http://www.hpm.org/survey/nl/b1/7
• CHSRP, Lisa Walton. "Nurse practitioner prescribing". Health Policy Monitor, April 2006. Available at http://www.hpm.org/survey/nz/a7/1

 

Author/s and/or contributors to this survey

Hoffmann, Christine and van Ginneken, Ewout

Empfohlene Zitierweise für diesen Online-Artikel:

Hoffmann, Christine and van Ginneken, Ewout. "Substitution of prescribing rights in Germany". Health Policy Monitor, 01/08/2010. Available at http://www.hpm.org/survey/ger/a15/2