Healthcare: another thing that the Germans just do better

Germany has rejected restrictions on doctors visits.

Recent Conservative ideas to restrict the number of GP visits in a year may be discounted as too controversial. But with the concept of universalism in health and welfare under threat we should not be so complacent. This is another area where we should follow the current trend of noting what has happened in Germany: consultation fees for visiting the doctor were abolished in Germany on 1 January 2013.

Co-payments, as they were called, of €10 if you visited the doctor in any given quarter or if you went to a specialist without a referral, were introduced by Schroder’s government in 2004. Addressing similar concerns to the NHS at present on health costs and the waste of doctors’ time on trivial conditions it was thought, at the time, to be a good idea by all the main parties in Germany. It was supposed to deter the practice in Germany’s compulsory health insurance system of patients hopping from specialist to specialist. They also thought it would bring in approximately €2bn per year.

Once in opposition the Social Democrats (SPD) and Greens turned against the idea of co-payments. As you would have predicted the charges deterred many people from going to the doctor. So it is obvious that the cost in dealing later with deteriorating conditions and in personal misery was great. Even on the projected revenue the German government did not meet its targets. When the abolition of co-payments was debated in the Bundestag last November the Financial Times Deutschland reported that medical practices spent approximately 120 hours a year collecting the fee, a total administrative cost of €360m. Once it came to a vote at the end of last year – coincidentally on the historic date of 9 November – the ruling conservative-liberal coalition (CDU/CSU and FDP) also changed their minds and the Bundestag voted unanimously to abolish the charge.

Could co-payments be introduced in Britain? The idea could be sold as a fairer method than restricting the number of GP visits per patient, it would be said "only those who can afford to pay will have to make this small contribution". But people of all income brackets have commitments to meet, whether it is a mortgage, rent or bills and any fee, no matter how small will deter people from seeking medical help. For those with long-term conditions the need to see your doctor regularly is clear. For the rest of us, also, we need to see the doctor when we have concerns. We may dismiss our niggling symptoms, but we will all get something serious eventually and it may happen sooner if, being human, we decide to spend our tenner on something other than going to the doctor for a trivial matter.

I would suggest that following recent top-down healthcare reforms it is only a matter of time before a formal proposal on GP visits is made – the Tory idea on restricting the number of visits is just to test the water. Universalism has not been defended but is a sound principle. It is more straightforward, we all contribute (even those on out-of-work benefits pay VAT) and we all benefit. The bureaucracy of means-testing is avoided. The case for the better-off benefiting is clear, we are all part of the community and the costs can be recouped by looking at the tax paid by the better-off. In terms of GP visits this is another case where we can learn from the way the Germans do things – a mistake was made but they reconsidered it and put it right.

Photograph: Getty Images
Photo: Getty
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The rise of the green mayor – Sadiq Khan and the politics of clean energy

At an event at Tate Modern, Sadiq Khan pledged to clean up London's act.

On Thursday night, deep in the bowls of Tate Modern’s turbine hall, London Mayor Sadiq Khan renewed his promise to make the capital a world leader in clean energy and air. Yet his focus was as much on people as power plants – in particular, the need for local authorities to lead where central governments will not.

Khan was there to introduce the screening of a new documentary, From the Ashes, about the demise of the American coal industry. As he noted, Britain continues to battle against the legacy of fossil fuels: “In London today we burn very little coal but we are facing new air pollution challenges brought about for different reasons." 

At a time when the world's leaders are struggling to keep international agreements on climate change afloat, what can mayors do? Khan has pledged to buy only hybrid and zero-emissions buses from next year, and is working towards London becoming a zero carbon city.

Khan has, of course, also gained heroic status for being a bête noire of climate-change-denier-in-chief Donald Trump. On the US president's withdrawal from the Paris Agreement, Khan quipped: “If only he had withdrawn from Twitter.” He had more favourable things to say about the former mayor of New York and climate change activist Michael Bloomberg, who Khan said hailed from “the second greatest city in the world.”

Yet behind his humour was a serious point. Local authorities are having to pick up where both countries' central governments are leaving a void – in improving our air and supporting renewable technology and jobs. Most concerning of all, perhaps, is the way that interest groups representing business are slashing away at the regulations which protect public health, and claiming it as a virtue.

In the UK, documents leaked to Greenpeace’s energy desk show that a government-backed initiative considered proposals for reducing EU rules on fire-safety on the very day of the Grenfell Tower fire. The director of this Red Tape Initiative, Nick Tyrone, told the Guardian that these proposals were rejected. Yet government attempts to water down other EU regulations, such as the energy efficiency directive, still stand.

In America, this blame-game is even more highly charged. Republicans have sworn to replace what they describe as Obama’s “war on coal” with a war on regulation. “I am taking historic steps to lift the restrictions on American energy, to reverse government intrusion, and to cancel job-killing regulations,” Trump announced in March. While he has vowed “to promote clean air and clear water,” he has almost simultaneously signed an order to unravel the Clean Water Rule.

This rhetoric is hurting the very people it claims to protect: miners. From the Ashes shows the many ways that the industry harms wider public health, from water contamination, to air pollution. It also makes a strong case that the American coal industry is in terminal decline, regardless of possibile interventions from government or carbon capture.

Charities like Bloomberg can only do so much to pick up the pieces. The foundation, which helped fund the film, now not only helps support job training programs in coal communities after the Trump administration pulled their funding, but in recent weeks it also promised $15m to UN efforts to tackle climate change – again to help cover Trump's withdrawal from Paris Agreement. “I'm a bit worried about how many cards we're going to have to keep adding to the end of the film”, joked Antha Williams, a Bloomberg representative at the screening, with gallows humour.

Hope also lies with local governments and mayors. The publication of the mayor’s own environment strategy is coming “soon”. Speaking in panel discussion after the film, his deputy mayor for environment and energy, Shirley Rodrigues, described the move to a cleaner future as "an inevitable transition".

Confronting the troubled legacies of our fossil fuel past will not be easy. "We have our own experiences here of our coal mining communities being devastated by the closure of their mines," said Khan. But clean air begins with clean politics; maintaining old ways at the price of health is not one any government must pay. 

'From The Ashes' will premiere on National Geograhpic in the United Kingdom at 9pm on Tuesday, June 27th.

India Bourke is an environment writer and editorial assistant at the New Statesman.

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