Don't get me wrong, but I don't think you know the German health system very well. The funding of the A&E Services differs among the different states but somewhat simplified the usual core principle is: the provider of the Accident & Emergency Service ( usually cities or counties) negotiates about the anticipated total costs in detail (budget accounting) and about the expected quantity of emergency responses with the compulsory health insurance funds. The agreed total costs are divided by quantity of emergency responses and the result is the charge per response. E.g. if the costs are constant and quantity of emergency responses is increased then the charge drops accordingly and the service gets the same budget. Only in order to claim the money from the patient's specific compulsory health insurance fund the mentioned doc's signature is usually required. The Accident & Emergency Service is non-profit-making and is *not* allowed to take profits. In conclusion: crucial for the service are the agreed costs and not how many punters you bring to the A&E Department. And anyhow most EMTs wouldn't care about management's budget issues (in fact I don't think most of our EMTs understand thoroughly how the Service is funded). You are right: most EMTs consider very carefully if the can leave a patient on the scene even if it's only a minor illness because the consequences could be grave (as I mentioned before). That's a sensible form of self-protection because the prosecutors don't care about the 1000 times you've been right, they only care about the potential mistake / malpractice. And even if the sentence is in the end one of acquittal until then you’ve got a time of horror. I don't think that's special for Germany and I suppose British EMTs aren’t less careful. It's correct the A&E Departments aren't as busy as in the U.K., but even before the system of out-of-pocket (it's not that old!) was introduced they weren't as busy. Some other possible causes (source: WHO): hospital beds per 100,000 in 2003 Germany: 874.56 UK: 397.65, Physicians per 100,000 in 2002 Germany: 333.61 UK: 212.61, GPs per 100,000 in 2002 Germany: 105.18 UK: 62.84, Total health expenditure $ per capita in 2003 Germany: 3001 UK: 2389. By the way: estimated life expectancy in 2003 79 years for both countries. 90% of the Germans are insured by the compulsory health insurance funds. In order to opt out of the compulsory health insurance funds salaried employees have to earn more than about 47.000 Euro per year (German average about 40,000 Euro). The benefits of the health insurance funds are statutory (SGB V). Only 4% of the whole benefit package can differ among the different funds. So in the absolute majority of cases the insurance funds can't decide if they pay or not and in case these decisions are usually made before the treatment. The patient doesn't have to pay first unless he decides to make a special agreement with the fund (bad idea unless you're rich) or you have *private* insurance cover, this refers to only 10 % of the population and these ones are for the most part more wealthy and save money by opting out of the funds. The new system of out-of-pocket payments includes e.g. 10 Euro per quarter of the year in case of GP consultation, same for the A&E Department 10 Euro per day in hospital up to a maximum of 280 Euro and so on... The maximum limit is 2% of the income and 1% for chronically ill patients. Of course these out-of-pockets payments are annoying, but otherwise the health insurance contributions would rise even more. So you are partly right, people start thinking about the need of treatments, but the system is not half as horrendous as you describe it. The real problems of the system are for example: these 10% mostly wealthy not contributing people and of course the demographic development (retired pay of course less than working citizens). The German health system is already very expensive and starts being hardly financeable.