Swiss healthcare on the brink of intensive care
Switzerland has an ageing population with more and more people suffering from complex health issues. This represents an enormous challenge for the country’s celebrated health sector. A dearth of well-trained staff exacerbates matters. People in the nursing profession have a lot on their plate – and are struggling to cope.
Swiss healthcare is in trouble. Costs are rising, reform is hitting the buffers, and a skilled workforce is in short supply. Nurses had already been voicing concern before Covid, complaining of poor working conditions and a lack of appreciation. After one and a half years of the pandemic, they are now physically and emotionally exhausted (see also “Swiss Review” 4/2021). But the pressure continues to build, as demographic and social factors aggravate the situation. Forecasts predict that the shortfall in nurses is likely to be around 65,000 by 2030. Employee associations and health experts warn of an emergency – which the “Strong healthcare” popular initiative aims to avert. This initiative will be put to the people on 28 November 2021.
Around 214,200 people work in the nursing profession in Switzerland – mostly at hospitals (45 per cent) and care homes (41 per cent). The remaining 14 per cent work in the home care sector. Many nurses work part-time, because the demands of a full-time position are simply too great. Shift rotas make it harder for them to have any sort of private and family life. The work is physically and mentally draining. And cost-cutting pressure across the sector has led to minimal staffing and a focus on efficiency above all else. Nurses often have little time to respond to individual needs or make small talk with patients. They find it hard to come to terms with the fact that they are unable to do their job the way they want. Many leave the profession early. A third of those who do so are younger than 35.
Foreign workers plug the gaps
Never before have there been so many job vacancies in the Swiss healthcare sector. HR departments are finding it hard to fill positions and often resort to recruiting people from abroad. At the Children’s Hospital of Eastern Switzerland, for example, 42 per cent of doctors are Swiss, 36 per cent are German and eight per cent are Austrian. However, 86 per cent of the qualified nursing staff are Swiss. The university hospitals of Zurich and Lausanne, on the other hand, rely much more on foreign workers, who account for around 60 and 50 per cent of the nursing staff respectively. It is also becoming increasingly common for private households to employ carers from Germany and eastern Europe. These women work virtually around the clock, earn relatively little, and return to their home countries after a few months.
The practice of plugging staffing gaps with foreign workers is problematic for ethical reasons. Switzerland is relying on people whom other countries have trained – and then lost. It will become harder to recruit workers from abroad in future, because other countries are now doing more to keep their best people. Nevertheless, staffing needs in Switzerland will continue to grow strongly, not least because of an ageing population.
Wealth of knowledge, minimal autonomy
In terms of the number of nurses per 1,000 inhabitants, Switzerland fares well compared to other countries. But according to Rebecca Spirig, professor at the Institute of Nursing Science at the University of Basel, it would be wrong to assume the sector is in a comfortable position: “We need to consider the whole picture. How do we deploy our nurses?” In Germany, for example, responsibility for wound care moved to the nursing sector only a few years ago, while administering injections and infusions is part of every nurse’s basic training in Switzerland. In the USA, nurse practitioners are responsible for providing primary care to the general public. And the Dutch have established their “Buurtzorg” (neighbourhood care) model, where teams of nurses are more or less free to advise and treat patients and make all the clinical and operational decisions themselves, accessing support from other specialists where necessary.
“Our nurses have great expertise but are rarely able make their own decisions.”
Professor at the Institute of Nursing Science at the University of Basel
“Switzerland does not lead the way,” says Spirig. Its health system relies heavily on doctors. “Our nurses have great expertise but are rarely able make their own decisions.” For example, patients in Switzerland even need a doctor’s prescription for minor things like wearing compression tights. Swiss healthcare also has layers of complexity. Anyone living at home with care requirements usually deals with a variety of specialists. Home nurses will change bandages, care for wounds and help with personal hygiene. Doctors will make diagnoses, provide treatment and prescribe therapies. Physiotherapists or occupational therapists will do the rest. “We have a lack of uniform structures and processes in outpatient care,” says Ursula Meidert of the Zurich University of Applied Sciences (ZHAW). There is often insufficient consultation. This can lead to duplication of effort or gaps in care as well as the wrong care.
Quality varies considerably
Like many other aspects of Swiss life, the healthcare sector has a federal structure. Federal government makes the guidelines, which the cantons then implement. The cantons delegate certain tasks to the municipalities, who in turn are partially responsible for long-term care as well as outpatient care for the elderly. Hence the availability of medical and social services varies considerably from place to place, as does the effectiveness with which these services work together.
Efforts are being made to make primary care more interconnected and efficient – not least in rural areas, where group practices have sprung up, pooling together different specialist areas. Models involving top-quality home care providers and a seamless interface with inpatient care also exist. These receive a degree of public funding. “We have evaluated some good solutions,” says Spirig. But there is a lack of political will to promote and implement these models across Switzerland, she adds. Meidert shares this view: “Many authorities only act when all other options have been exhausted.”
Stakeholders pursuing their own interests
The complexity of the system makes it harder to form correlations and initiate fundamental reform in the long term. Indecision seems to reign among national policymakers, who often get caught up in matters of principle and are rarely able to compromise. Many proposed improvements fail to get past parliament, where key stakeholders like the Swiss Medical Association, health insurers, and the pharmaceutical industry have a notable lobby. But voters also tend to be sceptical of reform proposals. In 2012, for example, the electorate rejected a plan that aimed to improve the coordination and quality of primary care. Those who oppose innovative solutions warn of higher costs, reflecting a common concern. However, studies suggest that uniform structures and efficient processes help to keep the costs in check. Once the various professions work together more effectively, staff will also be happier and remain in healthcare for longer. Rebecca Spirig, who is one of the committee members tabling the popular initiative, hopes that a yes vote will help to boost collaboration. “It would pave the way for reforms not only in nursing but within healthcare as a whole,” she says.
The public pays a lot
Healthcare services are expensive in Switzerland and are paid for mainly by the people who use them. In 2018, the bill was 798 francs per capita per month. Private households bore 63 per cent of the costs, with compulsory health insurance premiums covering just under half of the costs. The government covered around 30 per cent, according to the Federal Statistical Office. Health expenditure as a share of GDP has risen significantly in recent decades, accounting for 11.2 per cent in 2018 – one of the highest proportions in Europe. The USA easily topped the list on 16.9 per cent, followed by Germany (11.5 per cent) and France (11.3 per cent). Spain recorded 9.0 per cent and Ireland 6.9 per cent. The fact that costs are increasing is a source of concern for many in Switzerland – healthcare and health insurance consistently rank high on the annual Credit Suisse Worry Barometer. For the record: the highest costs in Switzerland are related to hospital stays, the lowest to preventive medicine.
Prescriptions to avert an emergency
For years, nurses have been calling for better working conditions, greater recognition and more autonomy. The Swiss professional association of nurses (SBK-ASI) now wants to take matters into its own hands at the ballot box. “Our health system will be on the brink of intensive care itself if we fail to make our profession more attractive,” says SBK-ASI director Yvonne Ribi. Supporters of the initiative want greater investment in education and further training. For example, they say that apprentice wages need to be increased to boost the number of graduates entering the profession.
The initiative also wants more people working per shift to ensure quality as well as patient safety. Rotas and working hours have to be more family friendly. In future, nurses need greater scope to prescribe, carry out and invoice certain treatments themselves. “Giving nurses more responsibility will ease the pressure on doctors,” says nursing academic and initiative committee member Rebecca Spirig.
Counterproposal to promote training
Policymakers have lent nurses a sympathetic ear. The federal parliament has approved a counterproposal, favouring a strategy that promotes training. Almost 500 million Swiss francs from the federal coffers has been earmarked for the proposal, with the cantons set to match this amount. That is too little, says the initiative committee. It believes that more is needed if carers are to have greater job satisfaction and stay longer in the nursing profession. The campaigners also want higher staffing ratios. Hence voters will have the last word on 28 November.
The Federal Council and majorities in the National Council and Council of States oppose the initiative. They are unwilling to afford nurses special treatment in the federal constitution. Health insurers also belong to the no camp, unhappy that the initiative would allow nurses to prescribe certain medical services themselves. They warn that this would lead to more frequent treatments and additional costs. The opposite is true, counter supporters. Not having to rely on a doctor’s signature all the time will save time and money, they say.