A 12-point reform is proposed by diaNEOSis in its new policy text, which concerns the governance of the NHS. Calling for a more efficient health system that better meets the needs of citizens and at the same time avoids the waste of material and human resources, the authors of the text speak of a “radical reform”, which is based on 5 axes highlighted by previous research of DIANEOSIS for a “New NEOS”. These axes concern its organization and administration, its financing, primary health care, hospital units and human resources.

The policy text now published comes as a natural continuation of this activity, and in particular attempts to further refine one of the five pillars of that research: that concerning the organization and administration of the NHS with a very specific proposal for modern governance reform of.

The NHS that was left behind and what can change

The structure under which the hospitals operate, “although it has changed many times over the years, the report points out, is still largely based on the structure of the NHS in the 1980s, when it was established”. But since then the needs for services in the country have changed, while better models of health system management have also emerged.

The inadequacy of this organizational structure of the NHS can also be seen from the results, the authors point out and add: “Staff, beds, clinics and laboratories are unevenly distributed, with the result that their distribution in the country does not follow the demography and needs health of the local population. Hospitals often lack necessary technological equipment, either for diagnosis/intervention or for recording and registering data – and where it exists, it is often under-utilized. Hospital emergency departments and outpatient clinics very often serve cases that could be treated at the primary level, outside of hospitals—thus freeing up resources and time for those cases that could not. Many, mainly provincial, hospitals lack important doctor specialties. Finally, there is no systematic and uniform recording of the needs of each Ministry of Education, with the result that each one’s resource needs are not clear and, therefore, effective planning becomes more and more difficult.”

The problem is much deeper than changing the selection process of hospital administrations, the signatories of the text point out. It is a group of four professors from Greek universities, coordinated by the emeritus professor of Social and Preventive Medicine at EKPA and director of the Institute of Social and Preventive Medicine (IKPI), Yannis Toundas and members of professors Vassilis Kefis of Pantheon University, Nikos Polyzos of Democritus University and Kyriakos Souliotis of the University of Peloponnese.

The Hub-and-Spoke Model for Organizing Hospital Care

The Greek health system, in contrast to many European ones, as the text says, “does not have either a central administration, or administrative staff selected by unchanging procedures”. The NHS is managed centrally to a very large extent by “weak services of the Ministry of Health” and certainly by the staffs of the ministers of each period. The structure of the NHS, as the policy text also states, seems to significantly limit the possibility of success of legislative or other interventions by the state itself in the health system.

The policy text devotes considerable space to commenting on the most recent trends in health systems management, noting that “in recent decades the trend has been towards shorter chains of command, the use of more multidisciplinary teams, task forces and horizontal structures, and towards larger limits of supervision, as the delegation of powers gains ground”. Therefore, the authors also find that the three levels of a health system (primary, secondary and tertiary) should be interconnected.

The authors stand by the analysis of the “Hub-and-Spoke” model for the organization of hospital care, which forms the basis of their own proposal. This model provides for the identification of a hub hospital that provides the most intensive medical services, has the highest investment of resources and the greatest concentration of the most advanced medical technology. According to the same model, around the hub hospital there are satellite-radius hospitals that offer more limited services distributed throughout the care network (at primary and secondary level), according to their size and the range of departments they have.

The 12 points of DIANEOSIS’s proposal for the “New NHS”

The proposal of diaNEOSis talks about the creation of a plan to create a “New NHS” and its authors code it indicatively in 12 points:

1. The NHS is re-established as NPDD, in order to operate as an independent public organization. In this way it acquires administrative autonomy from the political leadership of the Ministry of Health, where after the revolution the average term of office of a minister is less than two years.

2. The ESY is managed by a Board of Directors with a president/general executive director, who is selected by a special supra-party committee following an open competition, and members are the governors of the Ministry of Health (Health Regions), who are also selected by a similar procedure.

3. The Ministry of Health maintains its strategic and supervisory role, which is even being upgraded. It draws up the strategies, chooses the policies and sets the priorities in the organization and operation of the NHS, but without exercising its administration-management.

4. A Center for Strategic Planning and Evaluation is created as NPID, which is part of the administrative structure of the NHS together with ODIPY (Health Quality Management Organization) and KETEKNY (Center for Documentation and Costing of Hospital Services), which already operate as NPID.

5. The Ministries (NPDD) are increased to 13, corresponding to the Administrative Regions of the country or alternatively from 7 to 8 based on operational criteria, for better access of the local population to the NHS units. The new Ministries of Health will have greater participation in the planning but also in the provision of the necessary health services. At the same time, their role is strengthened by the transfer of management responsibilities from the central services of the Ministry of Health.

6. The NHS hospitals are converted into non-profit NPIDs and operate as subsidiary companies of the Ministry of Health. The proposed conversion certainly does not constitute privatization or a change of ownership regime, it is something that happens more widely in other sectors of the public sector and concerns the flexibility in the way of administration offered by this particular legal form. In this way, the hospitals maintain their exclusively public character, but thus gain greater managerial freedom to increase clinical efficiency and economic efficiency, and in addition, they adapt more easily to emergency needs or changes, e.g. the tourist season. The proposal places the conversion of hospitals into NPIDs after the formation of the National Health Service into NPDDs, the proposed Ministries of Health and the hospital networks.

7. One or more hospital networks are created in each Ministry of Health – the policy text suggests a total of 20, which it also specifies exactly – with a regional or university hospital as the hub hospital of the network, and interconnected with it, as spokes of the network , general prefectural hospitals or complexes of prefectural hospitals in the prefectural regions where more than one operate. Cases requiring tertiary hospital care are referred to the hub hospital.

8. Primary Health Care is organized on the basis of PHY networks (at least one per Municipality or one per apartment in large Municipalities), which are administratively under the PHY sector-directorate of the Ministry of Health. Each of these networks is functionally interconnected with the nearest hospital (basic and/or general), but maintaining its organizational and administrative autonomy.

9. A Health Center – which is in charge of the network – and the other primary units of the NHS of the geographic/population area of ​​responsibility of the network (ToMY, Regional Clinics, Local Clinics, etc.) participate in each PHY network.

10. Private personal doctors, Municipal Doctors and the private sector contracted with EOPYY are operationally interconnected in each PHY network. In order to have universal coverage, but also more efficient financing of the services, the text of DIANEOSIS proposes the extension of the institution of the personal doctor to the pediatric population with the inclusion of pediatricians and the expansion of the institution to other related specialties, especially for citizens with chronic diseases.

11. The PHY network is managed by the medical director of the Reference Health Center and by a 5-member governing committee, which includes representatives of: the Ministry of Health, the Local Government, the workers in the network structures and Civil Society (e.g. patient associations ).

12. Each PHY network develops an integrated package of family medicine services, which includes prevention and health promotion actions, treatment of acute and chronic diseases and health conditions, rehabilitation and palliative and supportive care offered in the doctor’s office, at home or in special health structures and care in the community.

Finally, the policy text devotes considerable space to how the transition from the current system to the one proposed on the basis of a costed business plan can be made. “In this way, this policy text constitutes a comprehensive and coherent proposal for the better organization and administration of the National Health Service. The implementation of such a reform can ultimately contribute both to the improvement of the health services provided to citizens and to the economic efficiency of the NHS itself”, the summary of the proposal text points out.