Class Composition with Wright’s Theory:
…we will try to apply Wrights structural approach to the small hospital I work at. As a reminder, Wright adds the three dimensions of control over money capital, over physical capital ergo the control over the means of production and over labour. The classification goes from no control (-) to full control (+) with partial and minimal in between.
The hospital I work at is the SRH KKH, a relatively small private facility with 4 wards (internal, parkinson, neurological rehab and icu) and a Hämosthasiologie for ambulant patients. The hospital belongs to the SRH Gesundheit Gmbh which itself is a daughter of the SRH Holding.
(Control over Money Capital, Control over Means of production, control over labour)
Nursing sector
Certified Nurse: (-,-,minimal/-)
Nursing assistant: (-,-,-)
Untrained nursing assistant: (-,-,-)
Nursing students (-,-,-)
Nurses in recognition (-,-,-)
Specialist nurses like wound experts or intensive care nurses (-, minimal, minimal)
Shift management (-,-, partial)
Ward management (-, minimal, partial)
nursing service management (minimal, partial, partial)
Social services (-,-,-)
Secretary (-,minimal,-/minimal)
Therapists (-, minimal, -)
Therapy manager (???) -> never seen
Support (on a unionist note, all of these but the last 2 fall out of the unionist wage agreement)
Cleaning stuff (-,-,-)
House technician (-,minimal,-)
Medical technician (-,-,-)
Cubes staff (-,-,-) -> they will have managers and directors too, kitchen
Security (-,-,-)
Reception (-,-,-)
Transport service (-,-,-)
IT (-,-,-)
Medical staff
Pharmacist (-,minimal.-)
Pharmacist assistant (-,-,-)
Medical assistants (-,minimal,-)
Laboratory technicians (-,-,-)
Head physician ( -/partial, +, partial) - this is the only group here dropping out of the unionist wage agreement and completely bargain for their wage, existing out of a basic pay and a percentage share of the bonus created by private patients
Assistant medical director/ senior physician ( -, partial, minimal)
Assistant doctor (-, minimal, minimal)
PJ/Students (-,-,-)
Administration
Managing directors (+,+,+)
Works Council (minimal, minimal, minimal)
DRG Decoder (-,-,-)
Human Resources (-,-,+)
Reflection on the classification
- The interprofessional team and the ability to delegate makes the control over labour hard to define
- The money flow is not defined enough, what does exactly define as minimal control over the money flow could be minimal investments or just the reshelving of the stock
Money flow
The financing of hospitals in Germany (all the maths part will have a chart)
Investment costs are paid for by the federal states
Operating costs are paid for by the health insurance companies. Every diagnosis is assigned a DRG (Diagnosis related groups) regulated by the KHG (Hospital law). Those DRGs are based on the average costs the hospital has based primarily on the diagnosis of the patient. A DRG is structured among others in: Description, Base Valuation relation, average dwell time, lower and upper dwell time, nursing revenue. The valuation relation is the main income source of the hospital, it is a number which is multiplied by the current base case value, which is decided on by a federal committee yearly, current value being 4215 Euro in BaWü. The lower dwell time is the first day with deduction, if the patient is discharged on that or before that day, a set value is subtracted from the remuneration. The upper dwell time is the first day with additional remuneration, however that bonus is much less than a new DRG would generate. The often forgotten but actually very very important last category, the nursing revenue is a daily valuation relation, based on the expected work of the nursing staff, not their costs. This relation is multiplied by the nursing base value, which is decided yearly by health insurance companies and the DKG, german hospital association, in which the SRH is directly represented, current value is 250 Euro
Let’s demonstrate all this in an example: DRG: B70A, a Stroke with neurological complex treatment. The base valuation relation is 1,807, this time 4215 is 7617,4 Euro for the treatment of the patient as long as he isn’t discharged before the 3rd day or after the 26th (upper n lower dwell time). The nursing revenue relation is 1,567, this means that for every day the company earns an additional 391,75 Euro. If we were to calculate the daily costs in nursing we could do a rough estimate by doing: 2800 Euro (wage) * 1/30.5 (one day) * 3 (ealy, late and night shift) * ⅕ (patients per nurse, ngl optimistic), which leaves us with less than 55.1 Euro a day in costs for nurses. This is making the daily nursing revenue 336,65 Euro, meaning the treatment of a patient for 20 days does not only generate 7615,4 Euro but an additional 6733 Euro with no further determination.
A huge part of the accumulated capital in other hospitals is the operating room, making up to 12k for implants or prosthesis, this falls out of our equation due to the simple reason that we don’t have an OP room. And lastly we got the Hämosthasiologie, making enormous profits while having neither significant labour nor room costs. The Hämosthasiologie is treating almost all of their 600 yearly patients outpatient and making (..) in total. It is impossible for me to calculate what sums exactly are made with the different additional fees for blood coagulation patients, as these fees are negotiated for each patient individually. Yet in the DRG catalogue it is noted that the yearly revenue per patient mustn’t be above 6000 Euro, which gives us a broad estimate about the scale we are talking about.
So, what kind of numbers are we talking about, especially in the SRH?
The numbers I am going to use will be from 2022, as no more recent annual reports are published. I will work my way through the activa, that’s where the money is invested, the passiva, that’s where the money from the investments come from and the Profit Loss statement.
The fixed assets, that are designed to permanently serve the SRH operations, are at 3.574.000 Euro. Obviously much of these come from the equipment, while interestingly only 5.000 is invested in machinery for the immediate production - whatever that is. It is also interesting that 2.174.000 Euro are financial investments in other companies, the first thought might be that this is the financial connection to the SRH Holding, this is however wrong. I can’t tell where the money goes, the only information given is that it is not back to the parent company. It is possible that all this is a middle man thing, transferring the money to a shell company which then transfers it back to Holding, but there is no proof of that whatsoever. Yet other companies additionally owe 13.Mio Euro to the SRH KKH, 2. Mio from the SRH Holding.
This money is created by: 520.000 is from shareholders, an additional 963.000 is the profit made through shareholders. 5.5 Mio are retained profits, this number is lowered by 945.000 loss carryforwards. 10.6 Mio are lent, 6.1 Mio of these from Holding.
The SRH KKH had a gross profit of 16.600.000 in 2021. About 12.7Mio are spent on wages and the insurance for the workforce. The rest looks pretty normal, some loss to funding and taxes, some additional profit from funding or interest charges. The only other thing that’s eye-catching is 3,457 Mio Euro for additional operating expenses, making 20% of the gross profit. And while it is once more impossible to see where exactly this money goes, it is a safe call to say that most of these are for rent. So it is finally visible how the SRH Holding does directly profit from the hospital, it is a tenant of its parent company. And, if one were to believe that these rents are just a small bonus for the SRH Holding which claims to be so progressive with its investments in health, rehab and schooling, Holding has repeatedly closed facilities that were unable to pay up, the ones I know of are a long time care facility and one of its hospitals. So even though the KKH only makes a surplus of 241.000 Euro, they fulfil their function in the company’s plan.
Lastly, we can try to determine where in the work process that money is made and reinvested: Firstly we can’t calculate which profession contributes most to the DRGs, the treatment is an interaction of all professional groups and saying that one group is involved way more in the medical care than the other is just stupid. On a side note, this also involves all the managerial stuff, while their jobs might be categorised as unnecessary in other societies, the current one needs these groups, funnily enough especially for the fulfilment of the DRGs. The nursing revenue we mostly covered before, obviously covered mostly by the nursing sector - this excludes therapeutic staff - in a few instances added by some of the support staff and the PJer, the student doctors.
This represents by far the largest group of employees having, other than wages, a very small cost factor: Other than medicine (which is paid for in the DRGs) and wound dressing there are no significant running costs, as most of the work is manual. The more structural machines like beds and monitors were mostly bought in the 2010 era if not before. The intensive care and diagnostic units fall out of that equation, having by far the most expensive equipment but therefore falling under higher paying DRGs too.
The other large source of income on the opposite - the Hemostaseology
has very few employees (3 or 4 secretaries and MFAs and 2 physicians) while dealing the most expensive medicine: An active man on a long term preparation of Factor VIII needs around 20.000IU a week, the estimated costs for the production of one IU long time preparation is between 1.50 and 2.50 Euro. This makes the Hämosthasiologie basically a pharmacy with additional DRGs, the actual surplus creation therefore is somewhere in a BAYER factory.
To finish up the reinvestment in the labour process we will briefly look at the wages (all gross a month): Nurses without bonus or specialisation 3.200€, most of the support staff minimum wage, so 1.920€, all the technical staff is paid somewhere between 2.500 and 4.00€, the therapeutic staff between 2.800 and 3.200€, nurses as mentioned before also 2.800, assistant physician 5.000-6.000€, assistant medical director 8.200-9.400€, head physician above 10.000€ plus private patient bonus.
Migrant labour
Before analysing the migrant flow in germany’s healthcare sector, we have to look at the state of the german apprenticeship as a nurse:
Germany has one of the lowest access conditions for a professional nurse; while most other nations require a completed university degree Luxemburg, Austria and Germany are the only EU states to use an in-company training combined with vocational school for the training of most of their nurses. While additional study programs are possible for management, nursing sciences, teaching or some specialisations (Palliative, Gerontological, Psychiatry…), those programs do require the basic education and are hardly used, due to them being assessed as unnecessary (only 1-2% use that chance). The training only requires finishing “Realschule”, the second best and second worst graduate and is even possible after finishing the “Hauptschule”, the worst graduate (by doing the nursing assistant first). This means that 10 years of school are required, in all other EU states it is 12. The Philippines, India and Brazil - 3 countries that will be more important later on - all mostly require a bachelor of 4 years in order to become a professional nurse.
Also it is noticeable that the BRD requires 2500h of practical labour in the training in comparison to 2100h of school - if this is to create cheap and in a way defenceless labour to battle the already huge but still rising understaffing is just a theory.
The official way of importing migrant labour is via the triple win program, designed to provide an already trained workforce from Bosnia, India (Kerala), the Philippines, Indonesia, Tunisia and Jordan. Vietnam is also part of this program, however only for people without training. The program is designed to school the foreign workforce and help them build up a life in Germany, responsible is primarily the GIZ (Gesellschaft internationale Zusammenarbeit - society for international cooperation) and the BA (Bundesargentur für Arbeit - Employment agency). I initially wanted to look deeper into that program, after a short research I found out that of the 236.000 migrant nurses who arrived and started working in 2021 only 3395 were provided by triple win. So I asked my colleagues and contacts from these places if there are any state or corporate programs in their transfer to Germany involved and while i found a few state programs like the Philippine Overseas Employment Administration (POEA) or the Overseas Workers Welfare Administration (OWWA), both for Filipino workers, those rarely get used due to them being deemed as unnecessary additional work.
The main regulations by the BRD are the policies regarding residence and work permit. A few of the relevant decisions in that regard: The Westbalkanregelung - western balkan regulation, which states that citizens from Albania, Bosnia-Herzegovina, Kosovo, North Macedonia and Serbia can a “privileged entrance in the german labour market” meaning their visa and work permit will be processed faster. From 2016, when it came into effect, to 2020 117.000 citizens of these countries made an application to work in the BRD, 11% working in the social sector, however this is also added by regulation in 2012 regarding highly qualified and shortage occupations, which had 34% and 84% of foreign labour end up in the social sector. Citizens from the Philippines, which is the latest development, importing the youngest workers only have official ways with the skilled immigration act (FEG), introduced in 2020, yet before that many philippine workers reached Europe via Saudi Arabia. With the FEG and its two revisions 2023 and 2024 it is theoretically possible for every citizen worldwide, in case they have the money for the flight and a training, to get a work permit in Germany and start as a nurse, the effects are yet hardly noticeable. It is noteworthy however that companies can pay 411 Euro for an accelerated procedure, which is intended to shorten the processing of recognition applications and visas, even grosser is that foreign workers above the age of 45 have to earn over 4.125 Euro or an alternative retirement provision to keep their residence permit, a nurse earns about 3.200 Euro before taxes, this makes the new “blue card” deal for nurses useless as well (wage >3.700 Euros)
Last relevant law is the recognition law, stating that all workers qualified in most non EU states need half a year of recognition. In that time the worker has almost no Protection against dismissal, nor a union wage agreement therefore being paid like an untrained labourer.
Also really interesting and important is the part 5, §22a of the “Verordnung über die Beschäftigung von Ausländerinnen und Ausländern” - “Regulation on the employment of foreign nationals” which literally states that nursing assistants do not need a stay nor work permit, if they work as a nursing assistant and have an accepted training, there is no evaluation to this regulation, I assume this keeps the mostly illegal live-ins alive.
It is also recognizable that many of the refugees from the arabic and persian countries as well as from Afghanistan, arriving 2014 and the following years, did end up in lower doctors positions while hardly any in nursing positions. The course for that is surely interesting as well, due to time reasons i will sadly not look into it.
A few consequences of this policies that i can observe in the SRH:
The fact that western balkan nurses arrived mostly in the years following 2016 or the Yugoslavian war built up an ethnical aristocracy within the team, as biogermans are hardly represented anymore, foreman jobs such as ward management or even nursing service management are taken by the now more experienced (both in language as in workflow) balkan colleagues while the normal nurse, nurse assistant etc. is getting more and more colleagues from east and south Asia, mostly Philippines, Nepal and India, such as South America and Mexico.
As all state programs apparently suck, all these immigrants are stranded in Germany without any connection, sometimes in SRH owned flats, leaving them completely isolated until they find their local community.
Both the precarian and the skilled sectors are purposefully stocked up with migrant labour, who often got a better training in their countries of origin than the german equivalent but have to face the reality that their entire livelihood is based on the residence permit, which will be cancelled as soon as they lose their job