Elderly care in Germany: are social innovations helpful?

The Buurtzorg model – or neighborhood assistance – comes from the Netherlands and has almost revolutionized the ambulatory elderly care sector there within a short period of time. The main characteristics of this innovation are the strong self-organization of the care teams, a holistically oriented care which always sees the patient in the center, as well as the smart integration of IT solutions.

Germany’s elderly care sector faces many challenges. Geriatric nurses cope with low wages, high time pressure, and high physical and psychological stress. Bureaucratization and economization of care exacerbate the issue. To address this, social innovations like the Buurtzorg model from the Netherlands show alternative ways of how elderly care could work. This model emphasizes self-organization of care teams, holistic care, and smart IT solutions. Although it has shown positive results in the Netherlands, more critical analysis is needed to determine its efficacy in Germany’s context.

Current situation of elderly care in Germany: why is there a need for social innovation?

Long before the pandemic, Germany was already discussing the “nursing emergency”. This refers to the “[…] strongly deficiently developed social safety net in case of need for care” (Schulz-Nieswandt, p. 15, 2018). Since the 1980s, Germany has experienced a noticeable trend of low fertility, an increase in the number of elderly people, and people living to increasingly older ages. The introduction of long-term care insurance in 1995 led to the employment of people in outpatient and inpatient care for the elderly, but the shortage of skilled workers has also increased (Theobald 2022). According to Theobald (ibid., p. 165):

“In 2018, 41 unemployed health care and nursing professionals were matched by 100 reported job openings, up from 86 in 2011”

There are multiple reasons for this shortage of skilled workers, including the precarious working conditions in elderly care.. The “[…] high time pressure due to low staffing levels, the high physical and psychological stress and the dissatisfaction with one’s own work due to the quality cutbacks necessitated by the lack of time” (ibid., p. 165) illustrate the precarious working conditions. Stagge (2015) describes in a survey conducted by DGB Index Gute Arbeit that nurses were very dissatisfied with their salaries (Stagge 2015). Stagge (2015) states: “48% of full-time employees earn a gross salary of less than 1,500 EUR according to this survey. 72% of employees earn a gross monthly wage of less than 2,000 EUR, making these wages precarious” (Stagge 2015, p. 76).

Dissatisfaction with wages is one of the important reasons for the shortage of skilled workers, but other working conditions, such as the strong bureaucratization of nursing in Germany, also contribute to this (Stagge 2015, p. 77). Legal requirements for care in Germany, such as the Eleventh Book of the German Social Code (SGB XI) on social care insurance, lead to high levels of bureaucratization in care. Geriatric nurses must not only provide care but also perform office tasks such as data documentation. The increasing economization of care in Germany also leads to pressure to reduce costs and generate profits. Stagge (2015) describes that care “[…] has to be organized increasingly under economic aspects” (ibid., p. 84). Lower wages for geriatric nurses are a result of this economization of care, as lower personnel costs save money. All of this has a negative impact on the care of people who depend on the services of geriatric care, as the shortage of personnel means that there are fewer people available to care for many elderly individuals in need.

Therefore, social innovations must close the shortage of skilled workers and thus the supply gap in care for the elderly that has arisen as a result of unattractive and precarious working conditions.

The Buurtzorg model / neighborhood model

In contrast to classic innovations, social innovations are not aimed at achieving potential growth or increasing competitiveness. They are much more designed to solve a societal problem and thus contribute to long-term change. As a rule, new approaches are to be used to acquire resources that are not yet accessible to social security systems. Social innovations therefore have a societal benefit and are usually intended to lead to greater equality, social inclusion, and social justice (Bock 2016).

In the following section, the so-called Buurtzorg model is presented. The Buurtzorg model or neighborhood assistance comes from the Netherlands and has almost revolutionized the ambulatory elderly care sector there within a short period of time. A central component of this social innovation is the overcoming of the Tayloristic division of tasks, as well as the strong bureaucratization, which often still prevail in the elderly care. The main characteristics of this innovation are on the one hand the strong self-organization of the care teams, a holistically oriented care which always sees the patient in the center, as well as the smart integration of IT solutions (Hamburg 2019). Important here is both internal communication (i.e. within the team) and external communication, with the patient and relatives. Internally, the classic hierarchical levels are to be dismantled as far as possible, so that communication takes place at face-to-face level. Externally, the approach is based on resources, which means that a realistic assessment of the patient’s abilities must be made. Another innovation is the division into small care teams.

Caregivers usually take care of a maximum of 5-6 clients in a team of two (Mayerhofer 2021). These projects are usually new enterprises and do not draw on existing organizations. This makes it possible for small care teams to be focused on a limited number of patients. In already existing companies, this transformation is usually not possible. Because of the existing problems in this profession, there are too few caregivers, but at the same time an increased need for care. In addition, the model provides that the care insurance funds pays workers by hour rather than by chargeable services. Since the Buurtzorg model is a best practice model, some pilot projects with this approach have also been introduced in Germany.

Braeseke et al. (2021) consider the biggest problem of social innovations in the field of elderly care to be the transformation of practice into the norm. They criticize above all that there is little to no scientific monitoring of the model projects, and thus a follow-up of the efficiency is often impossible (p. 9). However, the Buurtzorg model is already showing results, as it has already demonstrated strong cost benefits and improved job satisfaction in the Netherlands. Initial estimates in Germany predict that, first, the number of caregiver hours could be reduced by about 40 percent. In addition, there would be a verifiable reduction in emergencies and hospital admissions. This goes hand in hand with a cost reduction of 900 million euros for the nursing care insurance system in Germany (Hamburg 2019). These benefits should thus go along with improved working conditions, more personal responsibility, less stress and higher job satisfaction for the caregivers.

So a win-win situation?

The implementation of the Buurtzorg model is becoming difficult in Germany. On the one hand, there are critical assessments regarding the professional qualifications of caregivers in Germany. Since in the Netherlands nursing is an academic profession and in Germany it is a practical training profession. Another difficult point is the way in which services can be billed to health and long-term care insurance funds. Since in Germany each individual service has a certain equivalent value, it is not possible to charge caregivers by hours. For this reason, only individual pilot projects are currently being tested in Germany. It is apparent that individual projects have already failed.

In an interview, the former project manager Udo Janning reports that he has mixed feelings about the project. The development and implementation of the project went too fast, so that it had to file for insolvency due to additional influences. Nevertheless, Janning is convinced of the project and sees a great future in the model, if there would be more time for the introduction (Häusliche Pflege 2022). Other projects are currently still being scientifically evaluated, so it remains to be seen whether they will be successful.

Are social innovations sufficient to improve the situation of elderly care in Germany?

In order to improve the work situation of caregivers in elderly care in Germany, as well as to improve the quality of care, the Buurtzorg model shows an interesting approach. Since it improves the quality of care, as well as the working conditions for workers and reduces costs for care.  At first view, however, it does not seem to be sufficient to improve the overall situation. In our opinion, it requires a fundamental upgrading of the profession, including better pay for caregivers and working hours that make the job more attractive to more people. This also includes political changes, where the billing system is fundamentally redesigned, the bureaucratic burden on the elderly care system is reduced, and the state takes more responsibility for elderly care. Therefore, the entire system needs to be revised, particularly in light of the already advancing demographic change in Germany and Europe, and for this, projects of social innovation such as the Buurtzorg model are not enough. Especially since it currently cannot be applied to existing care companies.

References

• Bock B. (2016), Rural Marginalisation and the Role of Social Innovation; A Turn Towards exogenous Development and Rural Reconnection, “Journal of European Society for Rural Sociology”, vol. 56, n. 4, pp. 552-573.
• Braeseke G., Hahnel E., Neuwirth J., Engelmann F., & Lingott N. (2021), Potenziale sozialer Innovationen in der ambulanten Langzeitpflege [Potentials of social innovations in outpatient long-term care], Gütersloh, Bertelsmann Stiftung.
• Hamburg A. (2019). Soziale Innovationen: Das Beispiel Alter und Pflege [Social innovations: The example of aging and care], “Impuls zum demografischen” Wandel #2. Gütersloh, Bertelsmann Stiftung.
• Häusliche Pflege. (2021), Buurtzorg Deutschland – Ende einer Erfolgsgeschichte? [Buurtzorg Germany – End of a success story?]
• Mayerhofer B. (2021), Buurtzorg (Nachbarschaftshilfe) – die niederländische Alternative? [Buurtzorg (neighborhood care) – the Dutch alternative?], “Public Health Forum”, vol. 29, n. 3, pp. 227–229.
• Schulz-Nieswandt F. (2018), Stationaere Altenpflege und «Pflegenotstand» in der Bundesrepublik Deutschland [Stationary elderly care and the “nursing emergency” in the Federal Republic of Germany], Peter Lang International Academic Publishers.
• Stagge M. (2016), Altenpflege in Deutschland [Elderly care in Germany]. In Multikulturelle Teams in der Altenpflege [Multicultural teams in elderly care], Springer VS. Wiesbaden, pp. 51-67).