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German municipalities and their role in ensuring local primary health care


Bertolt Kuhn ,

Volker Amelung


Introduction: Today, “physician shortage” is widely discussed in German media. In some rural areas the assurance of outpatient medical care, nearby home, is threatened due to developments on supply as well as on the demand side. The ageing population in Germany leads to rising needs for medical services. Further, the regional distribution of physicians and needs for medical services increasingly seems to diverge. Big cities are more attractive to physicians than most rural areas. In addition, the population in rural areas is older and thus has a rising demand for medical care.

Smaller municipalities experience the problem of physician shortage in particular and are increasingly asked from local people to support local medical services with their own measures. However, by law they are not in charge of ensuring the supply of physicians. This is the task of the Associations of Statutory Health Insurance Physicians that plan and organize the distribution of physicians jointly with health insurance funds.

Various experts confirm the growing relevance of outpatient health care as a local political issue on the municipal and county level. Competition between communities for young physicians is one option to support and improve local situations. This, however, could also lead to an increasing local mismatch.

The aim of this study is to assess the political awareness of physician shortage on municipal level as well as to evaluate the implementation of local supporting measures in outpatient health care. Furthermore, we want to gather attitudes on a municipal level towards innovative models in outpatient health care.

Methods: Mayors and county administrators were asked for the local government perspective on outpatient medical care through a postal survey. The survey was conducted in August 2015. The study sample consisted of all 412 professional mayors and 38 county administrators in the federal state Lower Saxony in North-Western Germany.

The survey includes three chapters: 1. Assessment of current local physician supply (including availability and accessibility of doctors, vacancies in physicians’ offices); 2. Importance and influence of outpatient health care for municipalities (among others, the role of mayors); 3. Attitudes to innovative care models to support outpatient health care (nurse practitioners, patients’ buses, mobile physicians’ offices, telemedicine).

Results: The response rate was 70.9 % for mayors and 81.6 % for county administrators.

In every respondent municipality, there is at least one general practitioner. In 32.7 % of the municipalities, there is no further specialized physician. For 90.4 % of the respondents the outpatient care is an important location factor for their community. 71.3 % think the local disposability of general practitioners to be sufficient at the moment; 26.6 % of the participants claim a sufficient disposability of specialized physicians.

A need of municipal support for outpatient physicians is stated by 68.2 %. However, 70.1 % remark on obstacles for implementation, predominantly the lack of responsibilities and money.

Considering the attitudes to innovative care models, 70.4 % of respondent mayors support the use of nurse practitioners. 49.1 % vote for patients’ buses, 22.7 % for mobile physicians’ offices, and 12.5 % for telemedicine.

Conclusion: Especially small villages in rural countys in Lower Saxony state increasing problems to replace retiring physicians. Disposability of and access to specialized physicians seems to be a bigger problem for municipal leaders, compared to accessibility of general practitioners. For most mayors and county administrators, ensuring local health supply is an essential element for an attractive local infrastructure. Therefore, many municipalities consider various options to attract physicians or have already realized actions of support.

The supporting model with nurse practitioners is highly favored by municipal leaders. In contrast, telemedicine models, especially models encompassing remote treatment, are predominantly declined. Models to improve patients’ mobility get mixed reactions: While patients’ buses might help in rural regions with relatively bad short-range transport, mobile physicians’ offices are predominantly seen as too unattractive for physicians as well as too expensive for the health care system.

Ensuring and further developing outpatient health care is a topic of growing relevance for German municipalities. The survey’s unusual high response rate emphasizes the importance of the issue. Historically, municipalities have little responsibilities in the sector of outpatient care. However, according to a new federal law, municipalities are assigned new possibilities to act in outpatient care by employing physicians in public ambulatory healthcare centers. Whether local authorities should get more involved in planning and organizing physicians supply, is still discussed.

How to Cite: Kuhn B, Amelung V. German municipalities and their role in ensuring local primary health care. International Journal of Integrated Care. 2016;16(6):A206. DOI:
Published on 16 Dec 2016.


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