George J. Stathis
Health Management Consultant
President of GHSMAE-mail: [email protected]
The current hospital system in Greece is a direct result of Act 1397/1983 that established the National Health System (NHS). Laws that were later enforced brought about some changes, but did not modify the basic characteristics of the system.
The Greek National Health System is responsible for 327 hospitals, both in the public and private sector, totalling 51 762 beds (according to statistics from 2005). The average bed occupancy is 80% and the average length of stay is six days for the public sector and eight days for the private sector (excluding rehabilitation, chronic and psychiatric cases).
Act 397/1983 stipulated that all hospitals that received government subsidies had to be become public. This also applied to certain hospitals e.g. academic, military or those operated by social insurance funds. Staff in these hospitals became civil servants. Only two hospitals did not change their status, since they received funding from private donators; they have, however, maintained certain characteristics of a publicly operated enterprise. An important regulatory innovation was established by Law 3293/2004, namely that - for the first time – operates within the health care system a state-owned company in the healthcare sector.
Today there are 148 public hospitals in Greece: 115 general and 33 specialised, offering 35 814 beds in total. The largest hospital has 1 100 beds, while smaller hospitals have 242 beds on average. Thirty percent of public hospitals – which allocate 40% of all beds – can be found in and around Athens.
In 2005, GNHS hospitals employed 98 226 people. Doctors represent 23,5% and nursing staff 42,5% of the total. Only 19% of hospital staffmembers are graduate nurses (i.e. registered nurses). NHS doctors have their own salary scale, which is higher than that of other specialised hospital staff. In addition, doctors
receive compensation for after hour service (night duty).
Up to 2000 all public hospitals were solely dependent on the Ministry of Health and Social Solidarity for their annual budgetary funding. With the introduction of Act 2889/2001, an effort was made to decentralise health services and Regional Health Systems were created. However, these bodies do not have any power. Important decisions are still taken centrally by the Ministry. Currently there are 17 Regional Health Systems, but the Greek government recently announced that they will be cut back to seven and later abolished all together. The same Act also introduced the position of hospital manager for the first time; larger hospitals also have a deputy hospital manager.
The 179 private hospitals, called clinics, have a total of 14 528 beds, which translates into 75 beds per hospital. About 15 of these clinics are large, offering a few hundreds beds. These clinics are usually owned by a group of companies. Their patients either have private health insurance or pay from their own pockets. As these private clinics determine the cost of treatment and doctors’ salaries themselves, their cost structures are much higher than those of public hospitals, which, inevitably, leads to conflict with insurance companies.
Some small private clinics work within the parameters of social insurance funds. So, they charge daily hospital fees, as defined by the government.
Most of the larger clinics are general hospitals, while 53% of smaller clinics are specialised. According to law, the stocks have to be nominative if a private clinic belongs to a company.
A board of directors – seven members for hospitals with up to 399 beds or nine for hospitals with more beds - manages public hospitals. The government appoints the majority of the members along with the Chairman of Board who is the hospital manager. Until 2004 hospital managers were appointed for five years and could not be released, unless there was a (serious) official reason. From 2004, hospital managers have been appointed by the Minister for two years, without a contract and they can be released before the end of their terms.
In practice, hospital managers are considered political appointments. So, whenever the government changes after national elections or a new Minister of Health is appointed, most of the hospital managers are also replaced. This means that there are no more than five hospital managers who have served continuously from 2001 to 2006.
The most important criterion for public hospital managers is to possess an academic degree. Current legislation demands that hospital managers have additional qualifications, as well as proven industry managerial experience and any post-graduate qualification in healthcare management. There are no formal guidelines for the nomination, concerning these additional qualifications.
In the private hospital sector, general managers are selected according to meritocracy criteria. They already have extensive experience as a CEO and would thus receive remuneration reflecting their status.
The organisational structure of Greek hospitals is more or less similar in both the public and private sector.
Although GNHS hospitals have a Medical Directorate, each department or unit (e.g. pathology, surgery, nephrology) functions autonomously and has its own director, as in the private sector.
There is also a Nursing Directorate that is divided into sectors and departments. In public hospitals, there is a nursing department for every medical department or unit (e.g. operating room, intensive care, etc.). In private hospitals, it is more likely that one nursing department would take care of various medical departments.
The Administrative Directorate with sub directorates for the administrative and financial issues, deal with all administrative matters. The Administrative Director is in charge of staff, hospital budgets, moving patients, dietary needs of patients, secretarial support of all services, developing IT, etc.
All hospitals have a Technical Directorate, which is responsible for the maintenance of buildings, mechanical installations and biomedical equipment. In public hospitals, the biomedical engineering department falls under this directorate.