An assessment of international developments in health care highlights significant change on the levels of regulation, organisation and professions that can foster social inclusion. Major elements of global models of modernising health care are taken up in Germany but transformed in a country-specific way. Characteristic of the German model of governance is the centrality of physicians’ associations and SHI funds. This polarised model of stakeholder regulation favours the medical profession and nurtures professional strategies of exclusion and hierarchy. The comparative perspective highlights that the most powerful drivers for change, namely a primary care approach and restructuring the organisation of care, comprehensive regulation of all health professions and tighter public control through a system of accountability, are not used effectively in the German system. However, the German health system develops its own dynamics of modernisation and enablers of change. The objective of this chapter is to stake out the social fields of change, the arenas of negotiations and the players involved in Germany. The results of Chapters Two and Three are systematically linked in order to define the drivers for modernisation, and the enablers and switchboards of change, where processes of change cumulate and dynamics can therefore be studied empirically.

German model of modernising health care from a comparative perspective

Modernising health care in Germany is embedded in a global context of changing patterns of regulation and the organisation of providers and changing needs and demands on the provision of care. The transformation covers the organisational and occupational structures as well as the therapeutic concepts of health care; both levels generate clear impulses for change. What is particular to the German system is that marketisation and managerialism are used as a blueprint for restructuring a corporatist system, but not aimed at replacing it. The integration of new regulatory patterns in the existing system is a historically developed model of modernisation in Germany. The coexistence of change and continuity allows for a high flexibility and counts as a source of stability under conditions of economic and social change (Bäringhausen and Sauerborn, 2002). There is probably less uncertainty of the outcome of restructuring in the German system than in market-driven and state-centred systems.