Two reasons: Germany's much higher per capita income than England and it's federal structure. I won't comment on the first claim, it's self-evident. Germany is

Two reasons: Germany's much higher per capita income than England and it's federal structure. I won't comment on the first claim, it's self-evident. Germany is a federation of states: each state needs to provide adequate healthcare; states can't absorb spikes by distributing excessive patients to other states' hospitals (unless in a crisis) so they must over-provision infrastructure.