65 service groups, but no shared implementation plan
The hospital reform model is based on 65 service groups. For these groups, quality requirements, staffing conditions and structural criteria are intended to determine which services a hospital site may provide in future. The Federal Ministry of Health thus defines a framework under federal law for hospital care. The specific allocation of service groups to individual sites, however, remains part of hospital planning by the Länder. The requirements of the Federal Joint Committee for quality assurance are also relevant. Sources include the Federal Ministry of Health, Book V of the Social Code and the Federal Joint Committee.
The reform is therefore extensive in political and legal terms. Its operational question is narrower: Which site receives which service group, from when does the decision apply, what investment is required, and who independently verifies that the conditions are actually met? These questions determine the reform’s effect. They are not, however, brought together in a single public implementation plan.
The federal government changes the funding model and sets quality requirements. The Länder plan the sites. Hospital operators must adapt structures, maintain staffing levels and organise investment. Quality assurance operates through its own procedures and data. These responsibilities do not produce an automatic sequence. A legal framework is not yet an implemented decision about a hospital site.
Denmark consolidates planning earlier
Denmark organises its healthcare system into five regions. The regions bear central responsibility for hospitals and regional planning. The Danish Ministry of Health and the responsible health authorities thus describe a more consolidated organisational structure than exists in Germany. Local government is primarily responsible for tasks outside hospital care, while the regional level brings the hospital structure together.
The comparison does not prove that Denmark resolves every healthcare issue more effectively. It shows a different implementation architecture. Responsibility, site planning and regional coordination are located closer together. Decisions can therefore be organised more readily as a connected chain: need, site, service provision, quality requirements and funding are linked at the same regional level.
In Germany, this chain is divided. Service groups are defined under federal law, the Länder decide on hospital planning, and hospital operators implement the decisions in their facilities. Quality data and evidence are generated through additional procedures. The more bodies are involved, the greater the distance between a decision and its verifiable effect.
The federal government can set a framework. It cannot, however, determine on its own whether a specific site permanently meets the requirements. A Land can select a site. It cannot itself carry out every operational adjustment. An operator can invest. It does not, however, bear sole responsibility for regional healthcare planning. The reform distributes the tasks without creating an equally clear implementation route for the public.
The gap lies between the legal framework and the site
The structural gap is therefore not a single missing provision. It arises from the interaction of responsibilities, incentives and speed. The federal government has an incentive to formulate quality standards that are as uniform as possible. The Länder must take regional accessibility, political acceptance and existing structures into account. Hospital operators must manage financial risks and staffing issues. Each perspective is rational in itself. Together, however, they produce a process in which decisions may be postponed, documented inconsistently or made difficult to compare.
This becomes particularly visible during transitions. A service group may be assigned to a site while its physical infrastructure, specialist staff or technical equipment still require adjustment. Without a published deadline and a verifiable interim status, it remains unclear when a political allocation becomes an actually available service. Quality requirements then exist, but their connection to investment needs, site decisions and subsequent verification is not designed as a single public system.
The federal government defines the framework, but the effect only emerges through a regional decision chain that is barely visible to the public as a connected process. That is the cool diagnosis: The reform improves the architecture of the rules, but not automatically the architecture of implementation. The state defines the rules more precisely than it organises the transition.
Bauplan
The next step would be a public implementation register for every hospital site. It would not have to replace the entire hospital planning system. It would connect existing decisions in a common, verifiable presentation. For each service group, it would identify the assigned site, the applicable quality requirements, the established level of compliance, the necessary investment and the binding transition deadline. It would also have to show which authority made the decision and when an independent review would take place.
The federal government could specify a standardised data and publication format. The Länder would enter site decisions and deadlines. Hospital operators would report implementation status on the basis of defined evidence. An independent body would have to audit the information either randomly or when specific circumstances warranted it. The separation between planning and subsequent review would be decisive. Whoever assigns a service group should not alone decide whether the requirements have later been met.
Such a register would not create an additional operating theatre or new specialist staff. Nor would it resolve the investment backlog. It would, however, make visible which decision has been made, which requirement is still missing and when the next verifiable step is due. A distributed model of responsibilities would thereby become a traceable implementation chain.
The main pitfall would be an additional reporting obligation without consequences. A register would only function as an operating system if missing evidence triggered consequences for the service allocation, funding or further planning. At the same time, it would have to protect sensitive health and operational data. The public should therefore see the information relevant to structural decisions, not personal data.
Denmark shows that a more consolidated approach to hospital planning is organisationally possible. Germany does not have to adopt the same state structure. It can retain its federal division of responsibilities while still creating a shared implementation layer. A capable state does not begin here with another statement of principle. It begins with a complete, verifiable account of what is meant to apply at each site, and by when.
The relevant volume in the trilogy is Volume 3, “Bauplan”. The Projekt Freistaat Briefing examines such implementation gaps and the next steps required from the state.
AI-authored by Reinhard Brückner; editorial responsibility remains with the human publisher.