Triemli-Waid hospital is, like the cantonal hospital Obwalden and Lausanne’s university hospital, one of the last three dinosaurs in Switzerland’s health system having remained part of the public administration. All the other 180 acute care-hospitals enjoy greater independence and thus more entrepreneurial freedom: Zurich’s university hospital is, for example, an independent institution under cantonal public law; the Wetzikon hospital is part of a non-profit limited company; and the Insel Group in Bern operates as a foundation.

There are good reasons for this: running a hospital as an administrative unit has economic disadvantages, such as restricted financial autonomy and political interference in daily operations.  Former Triemli director Erwin Carigiet complained in a recent interview that the municipal council had to approve all recurring expenses exceeding CHF 50,000. When a company with 3,000 employees has to have every new expenditure approved by the city parliament, a loss of competitiveness is inevitable.

Part of the municipal administration: Triemli city hospital in Zurich. (Wikimedia Commons, Alessandro Della Bella)

Political interference reached a peak in 2017, when the Zurich city parliament demanded that Claudia Nielsen, the councillor then responsible, reported every six months on the progress of the new strategy. That gave Triemli’s competitors an advantage even before the strategy was approved, let alone implemented.

That was not the end of the story: a hospital integrated into a public administration inevitably gets caught up in political machinations. As a result, health policy decisions become hostage to non-partisan negotiations that have nothing to do with strategic hospital management. No wonder practically all Switzerland’s hospitals have abandoned such outdated governance structures.

Triemli’s CHF 167 million write off, announced in January 2020, is a perfect example of how complex the management of medical institutions has become. Progress requires expensive investments, while political pressure for more outpatient treatment has costly consequences. And the new hospital financing system, which severely limits subsidies for public sector institutions, creates major strategic challenges of its own.

Nevertheless, these developments alone cannot explain the blatant financial errors made at Triemli. The new hospital financing system was already approved at federal level in 2007 and medical progress and increasing competition have long affected all industry players equally. Four years after spending CHF 400 million on a new wing, the time has come to give Triemli legal independence. That would not mean a total loss of political influence on health policy: the canton of Zurich continues to define admission criteria for its so-called “list” of approved hospitals, ensuring clear qualitative and economic guidelines and stipulating the conditions under which performance mandates are issued – such as the management of an accident and emergency center.

However, hospital management alone should be responsible for implementing the performance mandate. Management alone should be accountable to its governing body (a foundation board, hospital board or board of directors, depending on the legal structure) and no longer to political authorities.

Independence is not to be confused with the freedom to act as one pleases, and certainly not with lower quality. On the contrary. Greater room for manoeuvre means more responsibility towards patients and staff. When bad decisions are made, it will no longer be possible to hide behind fickle politicians’ choices. Only thus could taxpayer funded million-dollar deficits be laid to rest just like the dinosaurs.

This text has been published as a guest article by TA-Media.