Stewardship of the Health Care Ministry PD Dr. Ulrike Kostka, Caritas Germany

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1 Stewardship of the Health Care Ministry PD Dr. Ulrike Kostka, Caritas Germany Ladies and gentlemen, I want to thank you for the invitation to your exciting conference. As a part of my work as a department manager of theology and organizational issues of Caritas Germany, and as a scientist, I have been working with the issue of the Catholic profile of healthcare facilities for a long time now. I am a theological ethicist and healthcare scientist, and have been working for many years with the ethical questions of the public health sector. By the way, I hope the translation of this speech sounds better than my own "poor" English. However, with a bit of humor and some patience, we will be able to talk with each other. Ten years ago, I had the opportunity of working in the USA as part of a post-doctoral research project concerning rationing in the healthcare sector. In this, I was honored and very happy to do this research with Professor Pellegrino at Georgetown University in Washington D.C. and later with Professor David Thomasma of Loyola University in Chicago. While I was there, I was able to experience the differences between, and shared problems of, the Catholic hospitals in the USA and later Germany, because both professors, along with their institutions, were responsible for consulting on ethical issues at the hospitals associated with these Jesuit universities. I am very thankful for the things that I learned there. The experience also showed me the great tradition that we, in Germany and the US, share through the catholic hospitals. At the same time, the frameworks are quite different, even now. In the US as here in Germany, the Catholic hospitals are in competition. In the US, things are much more competitive and the underlying conditions are different. The biggest difference is most likely that all German citizens have legally guaranteed access to healthcare insurance and their healthcare needs are covered by health insurance. The copayments to the legal health insurance providers have indeed increased, and individual patients have even had to learn that they cannot have everything that they might need. Overall, however, we are safe in making the assumption that everyone has access to, and can pay for, healthcare for everyone. This is quite different in comparison with the US. I hope that the Obama administration and its successors will persist in improving access to healthcare for everyone in the US. In Germany, however, the consensus must be continuously adjusted in order to provide a health insurance system financed through solidarity; especially as resources are becoming tighter and conflicts about the distribution of those resources are increasing. We also have an additional difference in Germany, under the church. The Catholic hospitals are organized under the Caritas, Germany. They form their own professional association, the Katholischen Krankenhausverband (which could be translated as "the Catholic Association of Hospitals"), which belongs to Caritas and does not represent a completely independent organization. By the way, I had the opportunity two years ago to visit the national headquarters of both the Catholic Charities, USA, in Washington D.C. and the Catholic Relief Services (CRS), USA, in Baltimore, with the President of Caritas Germany and to learn about their work. 1. Patient Healthcare Challenges 1

2 In Germany, stationary patient care has been exposed to a number of changes over several years. The relationship between the hospitals has become much more competitive. Through the reduction of the time spent in the hospital, the number of services has increased significantly. In this regard, the patients are often older, multimorbid and in need of care. The introduction of the diagnosis-related system has brought significant side effects on patient care along with it. The hospitals have significantly expanded their profile of services in the outpatient area. Mergers and new cooperative organizations as well as reductions in the number of beds shape the landscape of hospital administration. The quality and certification requirements on hospitals have also grown significantly. The financial pressure on hospitals is immense. At the same time, many hospitals have reached the limit of their capabilities, and their staves have also reached their limits. Some hospitals simply had to be closed; others have successfully stood up to the competitive conditions. The overall situation concerning the tariff system of Caritas has played a not insignificant role as well. Many hospitals have introduced the forms and tools of clinical ethical consultation. 17 years ago, the Katholische Krankenhausverband, as a professional association of Caritas Germany, together with the Evangelischen Krankenhausverband (which could be translated as the Evangelical Association of Hospitals) prepared the way for this beneficial process through their initiatives. Among the people, Catholic hospitals are greatly appreciated and have a good reputation. A higher level of expectation, both internally and externally, goes along with that. The patients assume that their needs will be perceived as, and taken, seriously and that they will be helped. Many hospitals (not just the Catholic ones) focus their attention on the human being when they formulate their guiding principles. In this regard, many hospitals are on the best of paths. Nevertheless, they are being subjected to a great deal of economic and competitive pressure. This burden cannot be transferred in one direction, to the staff. Ultimately, this is a responsibility of the facility itself, as well as of policy, because hospitals need general frameworks so that the human being can be made the focus of attention. Hospitals themselves must become more active and, for example, commit to regional networks. Caritas Germany Caritasverband, together with its professional association, the Katholische Krankenhausverband Deutschlands, is campaigning to support the diversity of hospital operators and for healthcare close to the patients' home. At the same time, we simply cannot support every hospital. For this reason, I see a future in hospital associations, which has many possibilities for synergy. Of course, the Deutsche Caritasverband is working together with the Katholische Krankenhausverband Deutschlands to find suitable financing for the responsibilities of hospitals. We all have to know that public healthcare has hit the financial limits and, for this reason alone, is voracious because of the demands induced by the service provided. A continuous increase in health insurance premiums, along with the well-known negative consequences for the entire social health insurance system must be avoided. To do this, we as Caritas Germany need a consistent position for the overall financing of the healthcare system. This also includes the debate about which expenses should be viewed as 2

3 not really belonging to health insurance and should be transferred to public financing over the mid-term. One very decisive question for the future of the services and facilities of Caritas will be the extent to which a sustainable tariff system within the scope of the tariff system of Caritas can be developed. In light of the existing lack of staff due to the demographic changes, this issue involves a future issue of remaining attractive as an employer. The Catholic hospitals are highly regarded as employers, because they have a clear profile of values. Ultimately, these values must be experienced, both internally and externally, in order to be trustworthy and attractive as an employer. For this reason, a trustworthy profile is not just a question of identity, but also a challenge in the competition for suitable employees. In addition to appropriate compensation for doctors, there is also a corresponding need for compensation of the healthcare support staff. Over the last few years, significant savings have been made in the area of nurses. At the same time, there is a debate about the question of which medical activities might be transferred to them. Nursing must remain attractive! It is a central profession in hospitals and indispensable. I know quite well that the hospitals alone cannot fulfill this responsibility. Initiatives on the part of the legislation and the hospitals, as well as favorable economic acknowledgement of the work provided by support staff in Germany are needed. By the way, compensation is much higher in the US than here in Germany. 2. Hospitals and Social Healthcare Hospitals make an important contribution to healthcare maintenance and recovery. At the same time, everyone knows that healthcare cannot be achieved by the healthcare facility alone. Healthcare depends a great deal on societal factors. People who are poor and without work are significantly disadvantaged with regard to their healthcare situation. As always, their life expectancy is significantly shorter. Being poor and disadvantaged makes people sick. This points to the relation between healthcare and social politics, which cannot be avoided. Social healthcare combines the material, cultural and social resources of a society into one view, which enables and cultivates a healthy life. In particular, the focus of the Deutsche Caritasverbandes is oriented on the healthcare situation of disadvantaged people. The goal is to provide people with access to the medical system and to support them once they are in it, so that they can lead healthy lives. This is an essential component for the encouragement of each individual's self-determination. For this reason, the hospitals have been challenged with supporting the patient's self-determination, even that of disadvantaged people, in the hospital. Out in the field, this is not easy, because the institution "Hospital" leads to the removal self-determination from the patient, very quickly because of its bureaucracy and very easily because of "expertness", and this quite often the case with disadvantaged people, who often live and behave quietly and helplessly. For this reason, the stereotypical staff often feels them to be a disruption of the operational medical course of routines. In this regard, each hospital must find its own methods of strengthening the self-determination of these people and their dependants. Quite naturally, the corresponding content in the education and continuing education of the staff is essential for this. The volunteer staff, such as those working with the Catholic hospital 3

4 aides, plays an important part in this. Their services are indispensable and a major blessing. They also need the acknowledgement and appreciation, as well as ongoing education, which go along with their work. I am very thankful that the Catholic volunteer aides are financially supported by the hospitals for their volunteer services. The hospital can make a significant contribution for social healthcare, when it considers itself as part of the community. The hospital cannot, and should not, be the point of contact for illnesses alone. Rather, it can become involved for healthcare in a community in many more ways, such as: through education, patient counseling and integration with other services. The cooperation of obstetrics departments with the family support services of the Caritas association is one concrete example of such integration. One challenge shared by the Caritas Germany and the Catholic Association of Hospitals is the shape of the public health sector in the future. This is being discussed yet again at this time. Which healthcare provision will we be able to provide in the future? Rationing: is this possible, or not? Rationing, meaning the withholding of necessary medical or support services, does exist already, even in the Catholic hospitals. Mostly, this is done implicitly by means of staff reductions. Quite naturally, we still have over-treatment and improper treatment in the system. Despite this, we cannot get around the debate about the setting of priorities, because a permanent increase in costs is not acceptable due to the limits placed on the resources. We must actively enter into this debate about the future of the public health sector. Caritas Germany has taken a clear position with regard to disadvantaged people, because they are the weakest link in the system. The proper shape for the public health sector must be measured by whether disadvantaged people who cannot get additional insurance, or make larger co-payments, receive sufficient and necessary provision of healthcare. In 2012, Caritas Germany will use "Solidarity and Health(care)" as the theme of their annual campaign. This will then provide a framework for also taking a stand for disadvantaged people. 3. The Hospital as Part of Caritas The hospitals are an indispensable part of the church and of Caritas Germany, along with it. However, many people do not know that the hospitals are part of the Caritas Association, because only a few hospitals use the name "Caritas" or display the Caritas logo. I would wish that the Catholic hospitals would present themselves more prominently as a part of Caritas. This also requires a consciousness building process, and that not just in the healthcare sector. This affects all of the services and facilities of Caritas. Caritas must learn to use the opportunities of cross-marketing more beneficially and to refer to each other more heavily. We can view ourselves as a large Caritas network, in which the various services and facilities work hand in hand with their employees. 4. The Hospital as Spiritual Experience Locations Catholic hospitals are facilities of the healthcare sector. However, they are also locations for spiritual and religious experiences. Many people experience the Church in a very concrete manner in these places. The hospitals are part of the Church's mission and their employees provide a religious service. In this manner, they become locations for experiencing the presence of God and can become something like a parish for people. 4

5 Our parishes are undergoing a difficult process of change. New pastoral areas and spiritual care units are being formed. These processes are not easy and imply many painful partings. On the other hand, they offer an opportunity for re-orientation, in particular, a new diocesan orientation. In many pastoral areas, this means that the various church groups in their communities, and the services and facilities of Caritas Germany are being re-discovered. One good opportunity is, for example, the shared creation of a social atlas, which consists of contact people for social questions in the associated pastoral area. In this process, I see a wonderful chance for us to confront ourselves as a church with a calling towards Caritas and to rely on each other. In this, the hospitals have a very important function. Often, the worship service in the hospital is a location for forming parishes. In this, hospitals can support parishes and experience themselves being supported. People find contact people and are guided to one another. I see a great opportunity, if the hospitals were to use the Caritas network, as well as the Church overall, more heavily. No hospital can perform its comprehensive mission by itself. It needs local support, volunteer co-workers and integration, even with the communities and the services and facilities of the Caritas association. The Catholic hospitals have a long history. They are an extremely valuable part of the Caritas Association, and thereby, of the Church. At this time, with regard to the current crisis in the confidence and trustworthiness of the Church in Germany as well as in the US, the charitable services, and thereby also the Catholic hospitals, can take on a decisive role, because they are involved with the society and can be a positive experience for the people. I know that many facilities worry about having a profile related to the Church, while at the same having the desire to avoid being swallowed by the whale of currently negative images of the Church. At the same time, however, we must consciously point out that the Church is more than just misuse, without denying the misdoings. We have to do everything possible for the rehabilitation from, and prevention of, such acts, even in the hospitals. Through our services and facilities and the Caritas associations above all, we should get involved in the process of improving and reforming of the Church actively and even significantly, and bravely lift up our voices, without sitting above everyone else. We can also bring many of the experiences of disadvantaged people and our work into the society, because the improvement process is not just about internal self-occupation. It is not about being a Church of the Holy Leftovers, but rather a church that points to and recognizes the signs of the times and a church that is involved with people! PD Dr. Ulrike Kostka Caritas Germany Deutscher Caritasverband Karlstr Freiburg Ulrike.kostka@caritas.de 5

Copyright American Psychological Association INTRODUCTION

Copyright American Psychological Association INTRODUCTION INTRODUCTION No one really wants to go to a nursing home. In fact, as they age, many people will say they don t want to be put away in a nursing home and will actively seek commitments from their loved