The history and future of physician manpower development in the Federal Republic of Germany.

The production, consumption and financing of health services in the F.R.G. take place within the frame of a comprehensive and highly bureaucratic social security system which covers nearly the total population. The health services system employs approximately 2 million people, costs more than 10% of the GNP and is still growing both in budget and manpower, in spite of the expenditure containment laws of the last 15 years. When considering the health care system in the F.R.G., one should bear in mind that it is rather a loose aggregation of subsystems, and therefore often characterized as a non-system. Whereas the degree of coordination and cooperation among the subsystems is rather low, competition for competences and funds is intensive. The health care system in the F.R.G. is dominated by the providers, whereas the consumers and the Sick Funds, which organize the latter, have little impact on the quantity and quality of services. The system can be regarded as an example for most of the fundamental critiques on health care services published worldwide over the last 20 years: it is disease and cure-oriented, and excels with regard to technological equipment and drug consumption. On the other hand, preventive approaches and quality control measures are negligible in amount. Planning and decision making in such a system are extremely complex processes, in which the governments, both the federal and the state ones, do not necessarily play the decisive role. With regard to manpower policy, it is important to stress the peculiarity of the strict separation of ambulatory and hospital services, forcing the postgraduate physician to work solely in either of them. This separation is so strict that, e.g., a practice-based gynecologist will not assist the hospital delivery of a woman, whose pregnancy he has followed-up over nine months. Assistance at the delivery will be given by a hospital-based obstetrician, who will at best have seen the woman only shortly before the event.