An interview with anesthesiologist Silvia Habekost about workload, the consequences of hospital reform, and the upcoming collective bargaining round in the public sector (TVöD).
Caro Rübe: Ms. Habekost, you've been working in the field of anesthesia for many years. What does your day-to-day work look like?
Silvia Habekost: I work in the operating room, and you can really feel the pressure to generate as many cases as possible. The focus isn't on patient care, but on performing as many operations as possible. Because there aren't enough staff, there aren't enough capacities available, and the available capacities are expected to be fully utilized so that there's no buffer left. No buffer for emergencies, no time to address the individual needs of patients. We work to our limits and beyond. That's unbearable full-time.
Are there no regulations to counteract the overwork of employees?
Our collective agreement for relief workloads stipulates a ratio for the wards, i.e., a ratio of how many patients the nursing staff can care for. If this is not adhered to, the nursing staff are given so-called stress points, and after five stress shifts, they get up to 15 days off per year, with the remainder being paid out. And that, of course, makes a real difference for each individual. It increases the pressure on ensuring there are enough staff. We also generate stress points in the operating room, for example, when I, as an anesthesiologist, look after more than one room. We also have a ratio in the recovery room. The workload doesn't decrease, but we get the same amount of time off as our colleagues in nursing.
In 2021, you worked hard to secure a collective bargaining agreement for relief at Vivantes and the Charité. Listening to you now, it sounds as if not much has changed since then.
There are already more staff. But the fact that there aren't fewer patients, but rather more, makes this contradictory. In areas where this works well, there are also better working conditions. Where the ratios are maintained, there are no days off, except in the case of short-term staff shortages. It also varies greatly from case to case. But because this economic pressure is so high, as soon as there are more staff, capacity increases. This doesn't necessarily lead to less workload.
The collective agreement on relief only applies to some hospitals. What are the most pressing problems nationwide?
Now there's the new hospital reform. Lauterbach promised that there would be a de-economization so that this competition would decrease, and he also wanted to abolish the diagnosis-based flat-rate fees. None of that has happened. If anything, it will get worse. This insanity of producing more cases will only increase. And the other intention of the reform was to close hospitals because there would be too many. But there is no impact assessment of what would happen if hospitals were simply closed without creating a structure to absorb this. It's a very complex issue. The system before the flat-rate fees was a cost-covering, needs-based financing system. Since the introduction of the flat-rate fees, needs-based financing has no longer been a priority. Prices were set for individual cases, which were average values. This led to competition for the most lucrative cases and who could best reduce costs. Since there were no binding guidelines for how many staff were actually needed, that's where the most savings were made.
But haven't these flat-rate per-case fees been partially abolished? Isn't the reform more about how much capacity hospitals have available?
Funding is still based on flat-rate fees per case. But there are now other flat-rate fees as well, namely provision fees. These are for provision costs that a hospital always has to incur. In the emergency room, for example, you don't know in advance how many emergencies will come. But basic costs arise because you have to maintain staff and the entire structure. When I hear that provision costs are covered, it tells me that, depending on the catchment area, this structure must be in place and financed. It shouldn't depend on how many ultimately come. But as the term "flat rates" so aptly suggests, the reform links this to the number of cases. Nursing costs for "bedside care" have been billed as a nursing budget for some time. This was a great success, and this system will remain in place. For all other areas—such as operating rooms, anesthesia, emergency rooms, radiology, etc., personnel costs continue to be covered by the flat-rate fees and will also be covered by the provision fees in the future—all without binding staffing requirements.
Does that mean that economic pressure is arising again?
Yes, that's not possible. If hospitals have more cases, they don't get more money. If they have fewer cases, the money is deducted and distributed among other hospitals. This means that this competition between hospitals over who cares for which patients will continue or even get worse. And this money for the flat-rate reserves can also be spent on other things; it is not earmarked money. Since hospitals are still allowed to make profits, one can imagine what the private, profit-oriented hospitals will do. The competition has already begun to have as many cases as possible so that one can be properly classified as a hospital.
What do you suggest instead?
We need sensible hospital planning; it must be financed according to needs, and it must be thought of from the patient's perspective, not in terms of money. Furthermore, the boundaries between inpatient and outpatient care must be abolished. There should be something like polyclinics again, not exclusively privately run practices or privately funded medical care centers. People always say it's all far too expensive. That's not true in that sense. We need to look at the revenue side. This hospital structural fund, which is supposed to be established now, is financed from statutory health insurance contributions and by the states. Why aren't private insurers held accountable? Why do I and my employer pay into the health insurance fund, but if you have an income from stocks and other property, you don't pay in? This redistribution of wealth is simply unfair. Furthermore, we need to finance the major structural changes through tax revenue or a special fund. Many hospitals are already facing insolvency – for example, because the increased energy costs in recent years have not been refinanced.
Let's zoom out again – nursing is care work. On the one hand, this means that its productivity can hardly be increased, and thus only generates profit under extreme pressure. At the same time, it means that it is feminized labor; meaning that the majority of women work in nursing under poor working and wage conditions. How does this relationship affect your union struggles?
For one thing, profit has no place in public services. People always talk about productive work, and then usually refer to the auto industry or some other industry. This is then perceived and presented as added value. But all the care work, which I include more than just healthcare, like education and childcare, and so on, is presented as if it doesn't create any added value. But you can't sustain an industry without care work. The costs of this must be factored in and cannot be ignored. The idea that you can make money from healthcare in general is completely perfidious.
Collective bargaining negotiations in the public sector are about to resume. Unions are currently primarily demanding more money and more freedom over working hours. Will this be enough to improve the situation in hospitals?
I think it's important that we demand more money. As far as I'm concerned, the demands could be higher. Demands regarding working hours, which would allow employees to choose between more money and more free time, are also understandable. That's the result of a survey that was conducted. But in our hospital, almost everyone has already reduced their working hours, and that's the case in many hospitals, not just in nursing, because this work is simply not possible to do full-time. Therefore, it would have been good to demand a general reduction in working hours with full compensation. Furthermore, there is a large proportion of precariously employed people in hospitals and other areas of the public sector. These colleagues must receive a proper pay rise!
Thank you for the interview!
If you would like to support Silvia and her colleagues, please contact us and stay informed:
Follow the Berlin Hospital Movement on social media @berliner_krankenhausbewegung
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Photo: Stefan Häusler
© 2025. This work is openly licensed via CC BY-NC 4.0 DEED
