A tale of two hospitals: the pandemic and its aftermath in Berlin and London – with Professor Heyo Kroemer and Professor Tim Orchard Episode 22 of the Health Foundation podcast

Dr Jennifer Dixon: The pandemic challenged every health care system in the world, but what can we learn from one another in the way we responded and how we might improve for future threats? Today, we'll be looking up close at the experience of two large academic teaching hospitals embedded in two different health care systems: the Charité in Berlin, Germany's largest teaching hospital, and Imperial College health care NHS Trust in London, one of the UK's largest. The Charité operates in Germany's health care system, which is financed by social insurance and delivered by a range of public and private providers. It also has much higher investment. Public spending on health care is £4,100 per head compared to £2,600 in the UK. There are more beds, doctors, and nurses per head, and policymaking on health is shared between federal government and the regional Länder. Imperial is embedded in the NHS and National Tax-funded system, with low numbers of doctors, nurses, and beds per head compared with Western Europe. And, of course, significant policymaking and decision making is centralised in the form of NHS England as well as by government.

Dr Jennifer Dixon: So how did these differences and more play out with handling the pandemic and dealing with its aftermath? What can we learn? Well, with me to discuss all this, I'm really pleased to welcome two leaders at the forefront of delivering health care during the pandemic: Professor Heyo Krömer, who has been Chief Executive at the Charité in Berlin since 2019. Heyo is a pharmacologist by trade who joined the Charité from the University of Göttingen's Medical Center, where he held positions of Dean and Chairman of the Managing Board, and Professor Tim Orchard, who has been CEO at Imperial College health care NHS Trust since 2018. He's a consultant physician and gastroenterologist joining the organisation as a registrar in 2000. Welcome both. So I think the first opening question has really got to be, how was the pandemic for you both?

Prof Dr Heyo Kroemer: You know, the German health system, it was kind of unprepared. We had all kinds of plans for pandemias and it was like what you read about the war: once the battle starts, all the plans are gone. That was exactly what happened here. In essence, as you know, Germany has a very expensive health system which works quite well. So to give you a figure, we spend €1bn per day on health in this country and have really a variety of hospitals, so when pandemia started, the quantity was there. Dealing with the problems initially carried real challenges. For example, in the beginning, we didn't have enough of simple things, like masks, like diagnostic tools, and all these type of things, but that had been established within a very short time. The problem when it started for us were in part the predictions, because for Berlin, the area of Berlin has, has 3.5 million inhabitants and we had a prediction that on Easter Monday, the last ICU bed would be filled with a COVID patient, and the Tuesday afterwards, we would have 200 patients standing in front of our hospitals, which we couldn't take care for. So that was a stressful situation which brought us to the necessity to increase our ICUs. We did that – from one week to the next, we added close to 80 ICU beds, because we had a previously used hospital which we could retake for that, but that required to concentrate staff from other clinics into this ICU thing, so that worked out. But what Berlin did was a unique reorganising its hospitals in that this 3.5 million people area, hospitals were stratified into four classes, and there was one hospital, which was Charité, which meant that in this 3.5 million people area, all severe COVID cases were concentrated at Charité, and there was one attending in our unit and he could decide on each and every ICU bed in the entire area of Berlin and attach the appropriate patient to these beds, and I just would like to give you a figure of what happened in here. In the change of 2020/21, we had something like 170 really sick people on our ICUs with COVID. We have in total more than 400 ICU beds here, but we had this number there, and at the same time, we had more than 40 people in parallel on ECMO, so the membrane oxygenation, which, as you know, requires lots of staff. So we had to concentrate the work of the entire huge clinics to COVID-19, which meant that we had to run down other parts of the hospital and I'm interested to learn what Tim did in this situation. So we had to cut down, for example, the activities in our operation theatres by 30%, which is, in a large place like this, quite a number. That resulted in neglecting other people with other serious diseases. So in other parts, like part of cancer, internal medicine, we could not fulfil our tasks anymore in the way we usually do. So that was a big shift in the internal organisation of the hospital. One of the problems I did not expect was, once the pandemia slowed down, going back to normal. Going back from this emergency state to normal proved much more difficult than we had expected. Overall, we could cope with that due to the organisation here in Berlin. It all worked out and our fatality rates on ECMO are less than the German standard, so we have some indicators that our people did a decent job here.

Dr Jennifer Dixon: Did you have to discharge a lot of people quickly as in March 2020, April? We had a big thing in Britain, as I'm sure Tim will talk about, to discharge particularly elderly patients in social care homes or into the community. Did you have a big effort like that or did you have enough beds simply not to have to do that?

Prof Dr Heyo Kroemer: We didn't have to discharge actively people. We had from the beginning, in Berlin, quite accurate predictions about what would happen within the next two weeks, so we could, in a coordinated fashion, slow down our activities in other parts of the hospital, so we did not have to actively discharge people whom we would have kept. So that was not a problem. We were able to increase beds in part and, in parallel, there was a coordinated decrease in parts of the hospital, so we hadn't had a problem. Of course, we had problems in retirement homes with the pandemia, which we can talk also about, but restricted to our hospital, we didn't have that particular problem.

Dr Jennifer Dixon: NHS is quite a centralised system in many ways. Were you going it alone on this as a hospital in Berlin, or how much central federal steering, guiding was there?

Prof Dr Heyo Kroemer: That's an extremely interesting question. As you know, after the last war, Germany got a very strong federal constitution. So most of the power, in particular in health, goes with the individual states, and so the many of the things we did, many of the laws and directions we got were from the state of Berlin. There were a couple of things done centrally - for example, it was, of course, early on noted that this COVID engagement would be a financial disaster. In due course, there has been compensation, for example, by the federal government. That was decided on the federal level, but the individual items and laws on health are frequently done by the state. We have a central federal law on the pandemia, but the details, they're all done by the state and this is kind of difficult because Berlin is a city state, so if you go to the next state, Brandenburg, you in part had completely different regulations, which is explainable to nobody.

Dr Jennifer Dixon: Right, and so things like coordination of personal protective equipment, masks and gowns, as you said, was that done at state level or was there some federal input?

Prof Dr Heyo Kroemer: There was federal input because in this federal law, which we had at that time, on a pandemic state, which could be declared by the federal parliament, there were some opportunities to declare things like this or to fix things like this, but most of the individual things like who's able to visit a hospital, what kind of preparations you do at a hospital, many of them were done on a state level.

Dr Jennifer Dixon: Yeah. Thank you. So, Tim, it must be interesting for you to hear some of this. Can you reflect and contrast your own experience at Imperial?

Prof Tim Orchard: Yes, very interesting to hear. I mean, so much is similar and yes, I guess, a few differences. I mean, I think the thing I would absolutely agree with is that whatever pandemic plans we had, I don't think that... when it came to the heat of battle, they seemed to melt away fairly quickly. I do think it's very strange now to reflect back on that time at the beginning of 2020. Just difficult to remember how frightened our staff felt because of this disease that was sweeping across the world and no one really knew anything about it. We were seeing a lot of pictures on the television of what was happening in Northern Italy at that time, of course, and I think that really affected everybody right the way through from the government down through to people on the front line. And I think if you then play in, the modelling was very interesting and of course caused a lot of concerns. So obviously, in the UK, it was actually the Imperial College modelling, of course, that led to the lockdown on the 23 March 2020, because that had suddenly suggested that half a million people might die. Imperial sits in Northwest London, it's a population of about two and a half million. It's the biggest of the five sectors of London, but actually, London as a capital came together and created this huge barn of intensive care beds, the Nightingale Hospital, over in the Excel Centre, and that was because there was a concern that we may need to have up to 4,000 ICU beds which, of course, was shocking on the one hand. So we all had to increase our own ICU numbers. And of course, it rapidly became clear that physical infrastructure in the NHS is a big problem. My own hospitals are largely ancient and so they're difficult to adapt, but of course, actually, outside of the physical infrastructure, the major problem was staffing, and if you create a brand new hospital somewhere else... and of course, at that time, the assumption was the major care issue would be about ventilation, that this was going to be a primarily respiratory issue and, of course, as we subsequently learned, people in ICU develop multi-organ problems and the problems with blood clots and all of those other things. So we then slightly switched to try and really build up our ICU capacity in our own institutions, because actually, it was much easier to flex the staff. We got up from our normal 84 beds at Imperial to 150 ICU beds, and we got to 132 ventilated patients the first, second week of April of 2020 and we were at 144 in January of 2021. That was the closest we came to – we were within a few beds, then, of running out. The things I would say had a significant impact were firstly, I think, as a country, we were very slow to adopt masks. I could remember at the beginning thinking, ‘Gosh, all of these people who are coming into work have come on a tube train that's been full of people who weren't wearing masks,’ and it took us a little while to think, actually, regular wearing of masks everywhere was a very significant thing. I think the PPE, the personal protective equipment issue was very significant, partly because there was a big job of work to do to make sure that people didn't overuse PPE – because, of course, actually, it's taking PPE off where you are most likely to infect yourself, so if you overdo it, you can actually run into a problem. But of course, there was a level of concern amongst everybody that we haven't got the PPE right, and so therefore they were being told not to wear PPE because there was a shortage, and actually, we never ran out, but we had to go to pretty superhuman lengths to make sure that we always had just about enough for the next day or two. The upside, if there is an upside, I think, was that we did show how adaptable we could be, and I think here in Northwest London, all of the five hospitals together worked and coordinated ICU beds, we transferred about 250 people between ICUs. We didn't have quite such a regimented structure, I think, as in Germany, which sounded like it was a very effective triaging service. There was more of a negotiation, but it seemed to work quite well. And of course, there was a lot of coordination actually across the whole of London, the 9 million catchment area of the whole of London, to try and make sure that we knew where the empty ICU beds were and how we could make best use of them. I think in electives, I think Germany did much better than we did. In the first wave of COVID, we got down, I think, to something like 10% or 20% of normal, so there was a huge reduction. We really focused on trying to keep our urgent, our cancer work going and I think we did quite well in that, but I think, again, we managed to learn so that in the second wave, we were down at a reduction of 40% rather than 80%. But that very first wave, I think everybody was so concerned about what sort of tsunami was going to hit us that we stood an awful lot of stuff down. Whether we would actually have needed to have done all of that, I think we will be an interesting point to reflect on.

Dr Jennifer Dixon: Yes, and of course we have fewer beds, doctors, nurses, and so therefore had to coordinate and had to step down more than it sounds as if was the case in Germany. I had two follow up questions for both of you on the pandemic. One was that, in Britain, Heyo, a lot of people I've spoken to have said we've introduced technology and new models of care in six days, and we've been trying to do this for six years. So there's a sort of acceleration of innovation that happened. The second was, as Tim says, that there seemed to be – and Tim, you can tell me otherwise – a lot more coordination between the hospital and the primary care and the community services and the care sector, because they had to, to keep the flow going. But I wondered if you could say something about the technological and service innovation during that period, and then the coordination with out-of-hospital providers as well.

Prof Dr Heyo Kroemer: We've seen the same thing here, and it was adaptation on the organisation side, but it seemed to be also adaptation on the side of the morale of the staff. When we started during the first weeks of pandemia, the percentage of people being sick were much lower than to regular times, so people were really engaged in fighting this particular virus, and with the safety issue during the first parts of the pandemia, we had almost zero infections in the hospital. That part worked out. In terms of acceleration, again, you've seen an unprecedented acceleration of things which you have to do every day in the hospital. For example, we needed new staff for various tasks, and we could hire people within one day, all a sudden, right? The unions agreed to do, we call it flash recruitments, and so things worked out which on the regular German bureaucracy are unheard of. The technological part of acceleration is kind of twofold. Part of it worked quite well, like sending people into home office and getting the appropriate equipment for that. That worked out well. Having digital ambulatory systems from the hospital, tailored medicine, that increased very well. On the other hand, in terms of information technology in health care, this is something which really hurt us during this pandemia. We don't have nationwide EMRs and these types of things. So the actual knowledge about the state of pandemia was very, very difficult to assess in our country. So the acceleration part was in part impressive; in part, it really focused on the things which didn't work before in Germany, which were really bad during pandemia. The coordination between different cares I think worked okay. The colleagues in private practice really did a very good job in treating those people who were not severely affected. So that really helped in hospitals that we didn't get a complete overflow, because many of the people were really managed in this part of the care. Otherwise, the coordination worked out not exceptionally well, but overall, it worked.

Dr Jennifer Dixon: And Tim, your reflections on those two things.

Prof Tim Orchard: Yeah. I think the models of care, absolutely right. I think the one thing I said, we redeployed 1000 staff out of our 14,500 in the second wave, but we knew, even with that redeployment, we were not going to have enough to cope with all of the tasks on ICU. So I think, for example, the introduction of non-registered support workers into our ICUs and actually carving out a new role to support ICUs – which we've now carried on, actually, after the pandemic – was a really important thing. So you had to look at all of these things and be incredibly pragmatic about how to deliver them. I think, looking again at Imperial, how the University and the Trust came together and had a regular research meeting and drove out these research projects really, really quickly, I think, was incredibly important. Of course, how that then translated into care so quickly, the coordination not only within universities and trusts, but across the country and across the world, and certainly you saw... it was very interesting looking at the outcomes in our ICUs. There was a 27% reduction in mortality between the first wave and the second wave, which I firmly believe to be as a result of the acceleration of research into the clinical environment. We've been trying to sort out telemedicine for years and years and years and, of course, on the 19 March, we said, ‘Right, all outpatients are now moving to virtual,’ and within 48 hours, we'd done something that we'd been trying to do for a decade. The danger, of course, is we do need to understand and do the analysis that says, ‘Well, what are the benefits of telemedicine and where is it not appropriate?’ and actually make sure that we are delivering what care the patients need. I think it would be dangerous to think that we should just swap and not do a bit of analysis. And then, in terms of coordination, I think the system did come together in a way that I've not seen before. We, in Northwest London, had a daily call between all of the hospitals, all of primary care, social care, to try and make sure we were coordinated. I think I come back to that point at the beginning of March, where everybody was very concerned and, as you mentioned earlier, Jennifer, there was, in the UK, a real push to get people out of hospital because we were so concerned to make sure we had the physical capacity in hospital to deal with people who were very sick, but certainly it became very clear in our part of London pretty quickly that there was a problem in care homes, and Hammersmith and Fulham council were very proactive and we were into those care homes doing testing on every single patient very, very quickly. I think if we hadn't had that really good coordination, that problem could have gone on for considerably longer. So I think... The challenge now is to try and keep those levels of coordination and build on them as we move forward.

Dr Jennifer Dixon: The main challenges that are now being faced by both of you in your hospitals after the big waves, I wondered if you could just take us through those, Heyo, from your perspective. Obviously, staffing and shortages and exhaustion will be one, won't it?

Prof Dr Heyo Kroemer: Well, yeah, I think that's an important question and I think what's very important... Tim just said it, to really carefully evaluate these experiences, and this is something I think we can learn from the U.S. They have these very thoughtful after-action reviews, and we tried to do that here, and there are quite interesting results from that. For example, Tim just said about success on the ICUs. For example, in the data wave, we had a clear problem on the ICUs because since the most sick people were concentrated at Charité, we also had an unusually high number of dying people at these ICUs, which carried an enormous stress, of course, on the staff. We carefully evaluated that and, at the end of the day, we put psychologists on each of these wards, and when we analysed that later, this small action of providing psych support on the wards turned out to be one of the most effective things, at the end of the day, as estimated by the staff. So where are we now? We are really trying to get back to our normal activities, but now we have this Omicron wave getting Germany and, as we speak, we have, again, 200 people of our staff infected, not at work today. So a major challenge is currently a shortage due to ongoing infections which are coming from the outside. There are no hospital infections, no in-hospital infections. We have general shortage on the nurse side, and this is due to a major demographic change in Germany, and then people after these two years are really exhausted. Changed job, reduced their working hours, and these types of things. So we are very much in the process of trying to cope with that. We have a new and really very different contract with the unions in terms of organising the work of the nurses, assessing once they get an overload and these types of things, so lots of efforts, but our main problem currently is really getting the workforce, and if you look in the entire workforce, the main problems are in the nursing part.

Dr Jennifer Dixon: Mm. And in terms of the backlog of care, you mentioned cancer. Could you give us an idea of that, Heyo?

Prof Dr Heyo Kroemer: Yeah, that's really an interesting cue, because in Berlin, you have a very high competition among hospitals so it's very difficult to assess whether this backlog resulted in simply not treating people or treating them later. So we have, in all our clinics now, high requests of patients, so with more staff, we could do much more currently, but it's very difficult to assess whether it's a real backlog problem or whether it's a problem of just returning to pre-pandemia normality. That is difficult to distinguish.

Dr Jennifer Dixon: What are you seeing in terms of waiting times for common elective surgeries compared to pre-pandemic?

Prof Dr Heyo Kroemer: Germany has, per person in our Republic, much more hospital beds than any under other country in Europe.

Dr Jennifer Dixon: Yes. 200% more than us, by the way.

Prof Dr Heyo Kroemer: That means if you look to the entire number of nurses in our country who are educated and who work, it's very high capita in Germany. If you relate it to the hospital beds, it's a very bad figure because we have too many beds. On the other hand, if you really want a procedure in the country right now, you will get it. Maybe not exactly where you want and at the place you want, but you will get something, because the overall coverage is still quite good. So waiting times, if you don't have a completely exceptional thing, this is manageable.

Dr Jennifer Dixon: Yes. When you say manageable, I'm just interested, how long would you wait, say, for a hip replacement?

Prof Dr Heyo Kroemer: I would guess you can get a hip replacement within a week.

Dr Jennifer Dixon: Right, thank you very much. Before I turn to Tim, who I'm sure is interested in that figure, I just want to ask one other question. In Britain, the NHS had a lot more funding from government to cope with the pandemic, and how did it work in Germany when, if your normal business, put it that way, of elective surgery went right down by 30%, your income would've gone right down, would it not? So how did you cope and did the federal or Länder subsidise you?

Prof Dr Heyo Kroemer: The answer is twofold. It was, to a large part, covered by the federal government. So there were billions of Euros going into the health care system to compensate institutions and hospitals for their lack of business, and as everybody was unexperienced, the first wave of compensation did not really discriminate. So there were a couple of small hospitals which wouldn't have played any role in fighting COVID who got large amounts of money, so that was probably the happiest time in their life during the beginning of the pandemia. In the later stages, it was more differentiated, and it was more related to really treating COVID patients. They did a very generous reimbursement for treating COVID patients, but at the end of the day, at least in the large academic medical centres like ours, it was not enough to really compensate for the losses. So then our owner, which is the State of Berlin, compensated the final losses. So, at the end of the day, it was a dual compensation effort both by the federal government and by the individual state.

Dr Jennifer Dixon: Very useful. Thank you. Tim, your reflections on the big things in the, quote, aftermath, unquote.

Prof Tim Orchard: Yeah. Well, I have to say, the thought of a hip replacement in a week does make me extraordinarily jealous. I think the issues that face us are probably the same sorts of things. I think they fall probably into three groups: there is our workforce, there is how do we deal with the workload, and then I think the thing that's really, really struck in England in the pandemic is the issue of health inequalities and how, actually, we haven't done enough historically to tackle health inequalities. I think the staff piece is quite similar. I completely agree with the comment about the psychological intervention, so we had targeted counselling in and around areas where we knew we had particular issues, but I do think we will have a problem that will take some months or years, really, to unpack as people process these very traumatic events in very different ways and on very different time scales. I certainly remember going to our gynecology ward, which doesn't normally see anybody die at all, and they were seeing 5, 10, 15, 20 people a week dying on their ward and I think it does take people quite a long time to recover from that. So I do think we've got that workforce issue and, of course, people who were nearing retirement are taking early retirement, so there's an issue about senior staff being lost from the top end of the workforce. And I think nursing vacancy rates are clearly higher than we were, and, of course, you then run the risk of getting into a bit of a vicious circle where you don't quite have enough staff, so the staff who are remaining are under more stress. So I think there's that. The other issue, of course, is if you think about the backlog. We went into the pandemic with nobody waiting a year for treatment, and we are currently sitting at about 1,600 people waiting a year. Now, I have to say our team has done an amazing job, because that was about 2,400 at one point, so we've got the numbers down, but yeah, it's an awful lot of people waiting far too long for treatment. I think there is a concern about how many missed serious diseases there will be, so people who didn't go and seek health care, and certainly, for example, in our breast screening service, we've seen demand go to 176% of what is normal and that's a real problem for us, just because you get these huge peaks of demand. I think it will take some time to work out when we've got back to a steady state. I think we're also then seeing people presenting later. So if I think about our urgent and emergency care services. When I was a medical registrar, which is longer ago than I would care to admit, you would see patients presenting as an emergency with late-stage cancer and that had really reduced, and now we're beginning to see more people presenting through emergency pathways that we would've hoped to have picked up through routine pathways. So I think that's a particular issue. And then I think we have to deal with the fact that, for whatever reason, the way that people seek their health care in England does appear to have changed. I don't think any of us really understand why or what the answer is, but we know that we are seeing more people coming to our emergency department this July than we had in July 2019, but we are admitting fewer of them.

Dr Jennifer Dixon: Oh, very interesting. I just wanted, on that, to ask Heyo, is he seeing the same in emergency departments in Charité?

Prof Dr Heyo Kroemer: Yeah, we have, but that was a phenomenon which started already prior to pandemia. We had more and more people coming to our emergency units, and the reason for that, I guess, at the end of the day, was somehow mixed because some of them couldn't get an appointment at their doctors or there were certain procedures which you know you would get at the hospital within a much shorter time than somewhere at your peripheral physicians. So that's a mixed problem which is, again, increased by staff restrictions because if various peripheral hospitals close, then their emergencies, they all come to us, and so there has been always a problem and there are different ways and means of trying to cope with that, which have not been very successful so far.

Prof Tim Orchard: Now a really interesting leadership challenge, I guess is how I would describe it, in order to try and galvanise our staff to focus on how we do provide care for all of those near now six and a half million people in the UK who are waiting for treatment, and I think we've suddenly become. We've, again, really focused on what other things that we can do to support staff to actually think really carefully and deliberately about things that will improve staff wellbeing, and Heyo indicated earlier, this isn't necessarily about doing massive stuff. It's about smaller things that just make life a bit better. I said our hospitals are pretty old and, in places, perhaps less sparkling and brand new than we would like, but we've just got a project that's ongoing at the moment to spend about £2.5m on improving the staff areas. And we've just created some flagship staff areas just for people to get a bit of downtime in the hospital where they don't feel as though they're stuck on the ward and can't actually relax. So I think there's a series of things that we can do and that we actually really need to give some attention to, and an important part of that, of course, is asking people what will make a difference to them because we've got to reset to focus on what is a pretty substantial task ahead. And then there is the issue of how we tackle health inequalities, how we make sure that we achieve equity of outcome in a way that perhaps we haven't done in the past.

Dr Jennifer Dixon: There's also an issue, isn't there, with, Heyo, we've got 6.5 million people on waiting lists in this country, many of whom are still waiting over a year... is how they are supported, because otherwise, they will require more and more help in the community by general practitioners who are feeling more and more under the pressure. So there's a big question there, and I don't know whether – before I just get finally to lessons learned, whether, Heyo, in Germany, you are seeing any interesting developments there on how patients can be supported. Are there any interesting developments there, innovations to try to support patients to self-manage or feel more confident about their condition in managing it, particularly given the huge wave of chronic disease you've got in Germany compared to Britain, oddly?

Prof Dr Heyo Kroemer: I think one of the major underlying problems which will emerge in the next years in Germany is really the demographic change we are facing. So within the next three, four years, it'll start those major factions of the workforce will retire, and due to the lack of subsequent generations, we won't be able to replace them. So we will run into a dramatic change in the workforce, which will then, of course, carry all the problems, which will result in health inequality and all these types of things. And Germany has also, like Tim described, very much neglected its infrastructure and hospitals. So it's not that we would have contemporary hospital infrastructure at each of the sites. It's really rare. The reason for that is that financing this infrastructure is part of the states, and the states didn't put money into that. So infrastructure is a kind of a nightmare and if you combine that with the demographic change, it's kind of an exponential nightmare. So the situation you see with the backlog will, independent of pandemia, most likely also come to Germany. So that's going to be a thing, and the solution, again, I think in part is really accompanying by digital modalities, because you can really... If you take one of these new watches where you can get an ECG and you get the oxygen saturation of blood or something from your watch, and you imagine that develops in a similar way during the next 10 years, you could really revolutionise medicine in that you don't have to see people at that frequency like we do today. We don't have very many options aside from that, if you accept the problem with the workforce.

Dr Jennifer Dixon: Exactly. So then comes the big, bold experiments using tech to try to accelerate the future. Finally, then, you both basically said how important it was to evaluate the experiences – your own experiences, and also those of others in the health system - to really learn as much as possible for the future. Some hospitals have written this up in Britain, we've got a national inquiry that is about to start, Heyo, on how we handled the pandemic, how the country handled the pandemic, including health, but absent that, while that is cooking, can I just ask you finally, if you were to crisply summarise what you think the big lessons were from your experience that you would hand over to your successors, for example, what would they be?

Prof Dr Heyo Kroemer: Yeah. The big things would first... be prepared in a better way. There are couple of things which won't happen to us again. For example, after a week, we run out of masks or something like this. This would certainly not happen again. Then a major point, interested in what Tim thinks about that, is to have proper communication at times of crisis, because I always thought that one of the largest problems at these academic medical centres was to have proper communication with your staff. We really changed that, and that was, I think, important. The really major point is improving technology, and in particular information technology, because we had a lot of capacities in the entire country and also the city of Berlin, and we could get much more out of these capacities if we would have a proper information technology.

Dr Jennifer Dixon: Yeah, thank you, and Tim?

Prof Tim Orchard: Yeah. The ‘be prepared’ one is absolutely right, but, of course, is also quite difficult because what are you being prepared for? But I think there is absolutely something about... we were not prepared for the scale of the pandemic that hit us. I completely agree that communication is really important and I think in big academic institutions, how you cascade stuff down is really important and tricky, and I think it takes much longer, normally, than you've got in an emergency situation. And I think there's an important thing about planning infrastructure, so I think that we spent a huge amount of time trying to convert space that was just not fit for purpose into ICUs, and I think every time we build new infrastructure, we need to try and make sure that we have actually fitted it out with the gases, with the power points, really quite basic stuff that will allow us to flex that, should we end up in an emergency situation.

Dr Jennifer Dixon: Mm, wonderful. Thank you both so much. I thought that was really interesting and I hope that sparks a good conversation. Maybe there'll be further links between you both in future, but I think you were both saying very similar and complimentary things, but very interesting contrasts as well. So I hope listeners agree with me that these were terrific insights from Heyo and Tim. Thank you both very, very much for these. We'll stick some useful links comparing the UK and the German health care system in our show notes, as ever, so please check those out. Next month, we'll be continuing the theme of leadership in health care, and so I hope you will join us then. Until then, stay well, and happy summer holidays.

• How does the NHS compare internationally? big election questions (2017) The King’s Fund 
• NHS hospital beds data analysis (2022) BMA 
• How does the UK compare internationally for health funding, staffing and hospital beds? (2017) The Health Foundation 
• Performance of UK National Health Service compared with other high income countries: observational study (2019) BMJ 
• What can England learn from the long-term care system in Germany? (2019) Nuffield Trust 
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• Health and care for older adults during the pandemic: What The Commonwealth Fund’s 2021 international survey reveals about the UK (2021) The Health Foundation
• Germany: Country health profile 2021: State of health in the EU (2021) OECD Publishing
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