The vicious circle of externalisation in German outpatient care

What it’s all about

In outpatient care in Germany, the trend has manifested itself of attributing problems that affect general practitioners and specialists in private practice monocausally to external factors such as bureaucratisation, digitalisation or a shortage of specialists. This externalisation of problem solutions, often accompanied by a monocausal argument, has numerous negative effects on the development of progress in outpatient patient care.

An example

Loss of staff in ENT practices: Externalisation

According to a report in the specialist journal “Ärzte Zeitung”, the professional association of German ENT doctors is reporting a “desolate staff situation” in practices. A survey found that half of all specialist practices are looking for medical assistants, with an average of one to three vacancies per practice. It is also reported that almost two thirds of ENT practices have lost staff to other practices, hospitals or the public health service in the last year, mostly due to employee redundancies. The main reasons for resignations are insufficient salary (36%), too much work (35%) and unfriendly patients (28%).

Although almost 51% of ENT doctors pay above the standard pay scale, they cannot keep up with the competition for specialist staff. This leads to longer waiting times and fewer examinations for patients. The association is therefore calling for a new calculation of the proportion of personnel costs in doctors’ remuneration in order to remedy the shortage of specialists. For example, the average salary of social insurance clerks should be used as a basis, as MFAs in surgeries earn significantly less than those in clinics or health insurance companies.

A look behind the scenes

However, the results of practice management comparisons show that the salary situation is only part of the problem, as only a small part of the best practice standard for staff management is implemented in ENT practices. This validated guideline describes all the tools, regulations and behaviours that are essential for effective personnel management in a medical practice. For example, there are hardly any feedback discussions, goals and values or professional practice meetings, staff suggestions for improvement are hardly taken into account and there is also a lack of appreciation for employees. These aspects also encourage the willingness to change.

The vicious circle of externalisation

There are many examples of this externalisation: Bureaucratisation, digitalisation, health policy regulations. The reasons are certainly valid, but only explain the causes of the problem in a very abbreviated and one-sided way. This is not without consequences.

Inhibition of initiative and innovative strength

The focus on external factors and the simultaneous reduction of the problem analysis to a single factor leads to an inhibition of the doctors’ and practice owners’ own initiative and innovative strength. Instead of looking for internal opportunities for improvement and developing innovative approaches to solving problems, many remain in a passive position, waiting for external changes. This leads to a standstill in the internal innovation process, which significantly impairs not only efficiency and productivity, but also competitiveness and the quality of care.

Concealing internal deficits

Externalising the causes of existing problems masks internal deficits, which can also play a role. For example, inefficient practice management structures, inadequate training activities or poor leadership and communication cultures within the team lead to difficulties just as much as the external factors mentioned. The monocausal argumentation fails to take the necessary systemic view of the practice’s own organisational and process structures, which prevents the identification and elimination of internal weaknesses. This inadequate self-reflection and lack of self-criticism inevitably results in a quality of patient care that is lower than would actually be possible.

Promotion of a victim mentality

The permanent emphasis on external causes promotes a victim mentality among the doctors and practice staff concerned. This attitude of being a “victim of circumstances” causes resignation and creates a feeling of helplessness. If the conviction grows that all problems are exclusively caused by external influences and that you have no influence on improving the situation yourself, the motivation to actively work on changes naturally decreases. This attitude reduces the willingness to take responsibility and initiative and has a negative impact on morale and commitment.

Lack of holistic problem solving

The monocausal approach and externalisation of causes prevent a systemic, holistic approach to problem solving. Many challenges in everyday practice are complex and multifactorial. The one-sided attribution of blame to an external factor means that other relevant aspects are not taken into account. As a result, many solutions to problems are often inadequate and unsustainable as they do not take all causal components into account. A holistic and systemic view would be necessary to achieve sustainable improvements, but is undermined by the monocausal argumentation.

Delaying necessary adjustments and reforms

The focus on external factors as the main cause of difficulties delays necessary internal adjustments and reforms. Many practices and healthcare organisations realise late or not at all that they need to be proactive in order to optimise their processes and meet the changing demands of the healthcare system. This leads to a backlog in the adaptation of modern management methods and technologies, which impairs the efficiency and effectiveness of practice management and worsens the care situation for patients.

Negative effects on patient satisfaction

Ultimately, the externalisation of problems also has a direct negative impact on patient satisfaction. When practices function less well due to internal inefficiencies and poor internal processes, patients suffer. Long waiting times, inadequate care and communication problems are often the result. Patients notice these shortcomings and rate the quality of care accordingly.

Difficult interprofessional collaboration

Another negative result of externalisation and monocausal reasoning is that it makes interprofessional collaboration more difficult. If the players in the healthcare system blame their problems mainly on external factors, collaboration is hindered. Everyone tries to solve their own challenges in isolation instead of working together on solutions that take all perspectives into account. This leads to fragmentation of healthcare and reduced quality of patient-centred care.

Conclusion

The externalisation of the causes of problems in outpatient care and the monocausal argumentation have far-reaching negative effects on the development of progress in patient care. This practice inhibits initiative and innovation, conceals internal deficits, promotes a victim mentality, prevents holistic solutions to problems, delays necessary adjustments and reforms, impairs patient satisfaction and impedes interprofessional collaboration. In order to achieve a sustainable improvement in outpatient care, it is necessary to overcome these negative tendencies and promote a more comprehensive, self-critical and solution-orientated approach.