On the vote on the Nursing initiative

On 28 November 2021 the Swiss electorate will once again be called upon to vote. We will be voting on a popular initiative proposing a new constitutional article and also, indirectly, on a counter-proposal of the Swiss Parliament, which will introduce a new law (Federal Law of 19 March 2021 on Nursing Training). Both the popular initiative and the counter-proposal aim at improving the healthcare system in a sustainable way.

In case of rejection of the popular initiative, the counter-proposal will be enacted, unless a referendum is launched. In this case, there will be another national vote on the counter-proposal. Even for the Swiss voter who is used to democracy this is a challenge. (Since the introduction of these popular rights in 1874 and 1892, there have already been more than 600 referendums).
  Undoubtedly, Switzerland has one of the best healthcare systems. However, there is no doubt that it still has to be improved. There are about 10,000 job vacancies in the nursing sector. In addition, a large proportion of doctors and nursing staff come from abroad. Furthermore, an increasing number of well-trained nursing professionals are changing jobs or even careers after just a few years. There’s a need for a debate on the causes and on possible solutions.

Popular initiative of the nursing association and counter-proposal of the parliament

The Nursing initiative wants to improve working conditions. The initiators propose a national collective bargaining agreement. Demands from the trade unions are already on the table. For example, Roland Brunner of the Zurich section of the Association of Public Services Employees VPOD said: 10 percent more salary for nursing staff, a reduction in weekly working hours to 36 hours and retirement age 60 with full pension – as in the construction sector (“Neue Zürcher Zeitung” of 27 October 2021). This might temporarily probably rather increase the staff shortage. The parliamentary counter-proposal doesn’t want any new regulation in this respect. Working conditions and wages would remain primarily in the responsibility of the cantons, companies and social partners. Regional differences – for example due to different living costs – could be taken into account as before. Furthermore, in exceptional cases, a collective bargaining agreement could be declared generally binding by the competent authorities on federal and cantonal levels. This approach has proven to be effective. In addition, it is controversial whether the main issue for nursing staff is the question of wages. Most nursing professionals want, above all, to have more time to care for and look after patients. That is why they have chosen this fulfilling profession.

Direct billing at the expense of the health insurance

Both the initiative and the counter-proposal want to allow more nursing professionals to bill the health insurance companies directly – without a doctor. This might well only be possible in Spitex (outpatient care and nursing services). It is doubtful whether this would lead to less administrative work and more time for the patient. At least, Parliament’s counter-proposal has a safety mechanism built in: If costs rise above average, the cantons could limit the number of nursing professionals or nursing organisations billing directly. 

Are standardised and centralised regulations useful?

Switzerland has gathered good experience with decentralised, flexible solutions. A few years ago, an initiative by the Social Democrats aiming at introducing a national standard health insurance fund was clearly rejected by the people. A popular initiative requiring standardised minimum wages for all professions had no chance as well. Flexible, bottom-up regulations – with company and regional collective labour agreements – are in line with the direct democratic system. They have been the basis for the industrial peace that has been contributing significantly to Switzerland’s economic success since the Second World War. In addition, in the current situation of staff shortages the nursing staff unions have a good negotiating position.

A bird in the hand is worth two in the bush?

The Federal Council and Parliament want to strengthen the ongoing training efforts in the nursing sector. The Federal Council wants to provide immediately additional 1 billion francs (for the period of eight years) if the initiative is rejected and the new law of the counter-proposal enters into force. If the initiative is accepted, Parliament will have to draft a law to implement the new constitutional article, against which opponents could launch a referendum, and there might be another vote.

Open questions

Neither the popular initiative nor the parliamentary counter-proposal provide answers to other problem areas in the healthcare system. The vote on 28 November must therefore be a starting point to keep on discussing further reform steps in the healthcare system in general and in an integral way – for example, on the question of how the profession can become more fulfilling and enjoyable again.  •