THE GERMAN MODEL

J. Brodehl

German Academy of Paediatrics and Adolescent Medicine, Cologne, Fed. Republic Germany

Primary care for children in Germany is mainly provided by paediatricians working in private practice. In addition, general practitioners and family doctors are entitled to take care for children also, and they do it mostly in rural areas where no paediatricians are available. The age range of paediatrics includes the phase from birth until the end of somatic growth, i.e. adolescence.

The number of ambulatory paediatricians is about 5,800, while 3,200 paediatricians are working in hospitals and 1,200 in community based institutions. Almost all ambulatory paediatricians are in primary care, only very few serve in paediatric subspecialties. Until now there is a strict demarcation between inpatient and outpatient paediatric care, and there is usually no primary care offered by hospital doctors. The annual birth rate in Germany is less than 800,000.

The vast majority of children (> 90%) are secured by public health insurance. Therefore almost all health expenditures are fully covered. The parents have the right of free choice for their paediatrician. Visits to the physicians are completely voluntary, and there are no beneficial incentives to follow the recommendations for routine primary care visits.

Routine regular checkups ("Vorsorgenntersuchung") were introduced in 1971 and cover the most sensible phases of child s development: 6 examinations (U1-U6) during infancy from day 1 to 1 year, one each in the 2, 4 and 6 year, and one (J1) between 13-14 years. In these routine checkups the milestones of physical and psychological development are controlled, specific disturbances ruled out, prophylactic measures as vaccinations introduced and parents counseled in details of care and up-bringung. The routine checkups are highly accepted by the population, i.e. 95% acceptance rate in the first year, thereafter, however, it declines somewhat. Besides these routine checkups the paediatricians provide every medical service possible in an ambulatory setting. Paediatricians claim to be the house doctor for the children.

The primary ambulatory paediatrician lives by the income of his/her practice. It was calculated that all measures of preventive paediatric care (routine checkups, vaccinations, counselling) amount up to one third of the time spent in the practice. For a long time these efforts were not adequately compensated for by the health insurance, however, recently the reimbursements have kept up with the working efforts and therefore primary care is a well accepted task of ambulatory paediatricians.