For decades, western Europe’s national healthcare systems have been widely touted as among the best in the world.
But an ageing population, more long-term illnesses, a continuing recruitment and retainment crisis plus post-Covid exhaustion have combined, this winter, to create a perfect healthcare storm that is likely to get worse before it gets better.
“All countries of the region face severe problems related to their health and care workforce,” the World Health Organization’s Europe region said in a report earlier this year, warning of potentially dire consequences without urgent government action.
In France, there are fewer doctors now than in 2012. More than 6 million people, including 600,000 with chronic illnesses, do not have a regular GP and 30% of the population does not have adequate access to health services.
In Germany, 35,000 care sector posts were vacant last year, 40% more than a decade ago, while a report this summer said that by 2035 more than a third of all health jobs could be unfilled. Facing unprecedented hospital overcrowding due to “a severe shortage of nurses”, even Finland will need 200,000 new workers by 2030.
In Spain, the health ministry announced in May that more than 700,000 people were waiting for surgery, and 5,000 frontline GPs and paediatricians in Madrid have been on strike for nearly a month in protest at years of underfunding and overwork.
Efforts to replace retiring workers were already “suboptimal”, the WHO Europe report said, but had to now be urgently extended to “improve retention and tackle an expected increase in younger people leaving the workforce due to burnout, ill health and general dissatisfaction”.
In a third of countries in the region, at least 40% of doctors were aged 55 or over, the report said. Even when younger practitioners stayed despite stress, long hours and often low pay, their reluctance to work in remote rural areas or deprived inner cities had created “medical deserts” that were proving almost impossible to fill.
“All of these threats represent a ticking time bomb … likely to lead to poor health outcomes, long waiting times, many preventable deaths and potentially even health system collapse,” warned Hans Kluge, the WHO regional director for Europe.
In some countries the worst shortages are among GPs, with France in particular paying the price for previous planning errors. Back in 1971, it capped the number of second-year medical students through a so-called numerus clausus aimed at cutting health spending and raising earnings.
The result was a collapse in annual student numbers – from 8,600 in the early 1970s, to 3,500 in 1993 – and while intakes have since climbed somewhat and the cap was lifted altogether two years ago, it will take years for the size of the workforce to recover.
Even though 10% of France’s GPs now work past retirement age, older doctors leaving the profession outnumbered newcomers entering it last year, when numbers were still 6% down on what they were even a decade ago. It could be 2035 before the country reaches a satisfactory ratio of doctors to inhabitants nationally.
Local provision, however, is another matter: GP ratios range from 125 or more per 100,000 people in some wealthier neighbourhoods to less than half that in remote rural France or deprived suburbs such as Seine-Saint-Denis.
“In fact, about 87% of France could be called a medical desert,” the junior health minister Agnès Firmin Le Bodo said last month, pledging a “complete rebuild” of GP services through more multi-function health centres and remote consultations – but no obligation, as yet, on doctors to set up in poorly provisioned areas.
This winter’s flu epidemic, coming on top of Covid-19, had exposed the system’s failings, creating “a crisis not just for France’s hospital sector but for all of French healthcare”, said Arnaud Robinet of the French Hospitals Federation, warning that the service was “no longer capable of responding systematically” to emergencies.
In Germany, which spends more on healthcare than almost any other country in the world, hospitals are a greater concern, with this winter’s wave of respiratory syncytial virus (RSV) in young children triggering alarm across the country.
Amid reports of overcrowded casualty departments and parents forced to sleep in hospital corridors or travel hundreds of kilometres for a child’s treatment, the Süddeutsche Zeitung said the country was witnessing “what it means when a system implodes … in scenes which for a long time might have seemed unimaginable”.
In a petition to parliament titled: “Alert level red – hospitals in danger”, the German Hospital Society (DKG) again highlighted a chronic lack of staff as the main problem, noting that many hospitals had had to temporarily close casualty departments due to a lack of doctors and nurses.
More than 23,000 posts remain unfilled in Germany’s hospitals after several years of low recruitment and recent mass resignations, particularly in intensive care and operating theatres, by staff citing a workload so extreme that some were unable to take even a short break or go to the toilet.
The health minister, Karl Lauterbach, has announced a €300m (£260m) aid package for paediatric clinics and an as yet unspecified “revolution in hospital care” putting “medicine first rather than the economics”, plus a plan to move nurses and doctors around to match demand that was dismissed as “absurd” by leading medics.
“The problem is we have no wards that could do without staff, because they’re all already only able to offer the minimum level of care,” said Christine Vogler of the German Council of Nursing (DPR). “This can only be called an act of desperation.”
Christoph Spinner, a consultant in infectious diseases at Munich’s University Clinic, said the country’s health system was “without doubt facing enormous challenges”, while a paediatrician, Nina Schoetzau, said the state of Britain’s NHS was “a taste of things to come” for Germany.
In Spain, the winter has already prompted overstretched frontline staff to take strike action. The healthcare crisis, laid bare during the Covid pandemic, follows decades of under-investment, competition between regions for medical staff, and the lure of better pay and conditions abroad.
Much of the discontent has focused on the Madrid region, where in mid-November at least 200,000 people took to the streets to defend public healthcare against creeping privatisation and to express concern over the regional government’s restructuring of the primary care system.
Ángela Hernández, a surgeon and general secretary of Madrid’s AMYTS medical association, said the situation in paediatric services was “practically desperate”, adding that it was also “about demand: no one is telling people that if resources are limited, services have to be used wisely”.
Politicians had a responsibility to “explain the situation to people”, Hernández said. “But because they do the exact opposite in Madrid and in Spain, they raise people’s expectations.”
The Metges de Catalunya (Doctors of Catalonia) union also plans a two-day strike next month to protest against “overload, disdain and precariousness”. Xavier Lleonart, its general secretary, said the pandemic was “the icing on the cake” but the current situation was as foreseeable as it was depressing.
Some Spanish doctors were so burned out they were taking early retirement, despite the hit to their pensions, he said, adding that the chief imperative was to make the profession more attractive to stop the “haemorrhage” of professionals.
“People say the best capital a company has is its human capital,” Lleonart said. “The problem is that in health the human capital has been systematically mistreated until it has said: enough’s enough.”
Italy’s public health service, too, faces serious staff shortages, compounded by the pandemic, which triggered an exodus of staff from the profession, taking early retirement, or switching to roles in the private sector.
Regional governments have signed contracts with freelance medics to cover hospital shifts where needed, highlighting the low salaries of Italy’s public health sector.
“There are holes that need to be filled everywhere, especially in emergency units,” said Giovanni Leoni, vice-president of an Italian doctors’ federation. “The issue is that freelances earn two to three times more – up to €1,200 for a 10-hour shift.”
Many medics had left public sector roles “before their time”, Leoni added. “They have found other types of jobs in the private sector – roles that mean they don’t have to do night shifts, or weekends.”
Italian medics are holding a demonstration of “the invisibles” later this week. “We’re invisible for the government,” said Leoni. “Salaries for Italian doctors need to be at the same level as those in Europe. Currently, they’re among the lowest.”