On 2 December, 2022 , the Greek Parliament passed a new law for “Secondary care, medical training, salary arrangements for all NHS doctors and dentists and other provisions of the Ministry of Health’s competence”. Among the measures introduced by the legislation, by far the most controversial are the change in labour relations and conditions for the doctors working in the National Health System (ESY) as well as the introduction of dual- practice, allowing doctors to combine working in their public sector positions with working in private practice. The law has sparked widespread protests by doctors’ unions.
The main provisions of the new law that have raised strong opposition are the following:
1) The conversion of persistently unfilled posts into part-time positions
There are currently a number of advertised doctors’ positions within the National Health System, which remain unattractive to doctors and fail to attract any applications; consequently they remain unfilled. The new law allows the Minister of Health to transform these positions from full-time to part-time posts (upon the recommendation of hospital directors, if the position is in a hospital, or of the directors of the relevant Health Region, if the position is in a health center or multi-functional regional clinic). The same procedure allows any unfilled position in “problematic” areas (for example, remote areas or within particular medical specialties) currently experiencing shortages because they are unattractive to doctors also to be converted into part-time positions.
The doctors taking these posts have the status of private practitioners contracting with ESY, rather than salaried civil servants, which is the case for doctors employed full-time within the National Health Service. The appointment of the doctor in a part-time position has a duration of three years. Upon completion of the three years, the position is re-advertised and either may be converted into a full-time position or retained as part-time employment. The incumbent physician needs to reapply for the position and may remain in post until it is refilled.
Doctors with part-time status work three days a week in a seven-hour, continuous morning regular schedule, participate in the on-call program of hospitals and receive a pro-rata salary equivalent to three days of a full-time doctor’s salary in the relevant branch of the National Health System.
Physicians who are appointed to part-time positions within ESY retain the right to alternate employment in the private medical sector and the right to maintain a private practice or dental practice.
2) Employment in the private sector of doctors also working within the National Health System
The law now makes it possible for doctors currently working within the National Health System who serve in ESY hospitals to also operate a private practice or to provide medical services with any relationship, including that of a consultant, in a private clinic or private diagnostic or therapeutic laboratory and in general in any kind private business that provides or covers health services.
Conditions apply, such as requiring the permission of the hospital director and limiting private practice to twice a week. In addition, doctors are required to participate in the operation of the hospital within its “regular hours”, as well as outside its regular hours for at least 8 shifts a month. There are also limits on the number of cases involving diagnostic procedures or para-clinical examinations, surgical and interventional procedures performed outside the hospital (that is, in private practice) per week: these may not exceed one third of the weekly number of cases treated by the same doctor during his or her employment in the public hospital.
In addition, ESY doctors, other scientific and nursing staff, as well as university doctors, are now allowed to participate in working groups such as “Expert Advisory Committees” for drugs and treatments, with a strictly scientific content, that take place in Greece or abroad and are organized by pharmaceutical companies, with or without remuneration, as long as they have received a relevant license from the body that supervises them. This was previously allowed only for teaching and research staff in university hospitals.
Members of medical and laboratory teaching or research staff in higher education institutions who are doctors and work in ESY hospitals, clinics or laboratories have also had their opportunities for private practice expanded. Previously, they could own their own private office outside their place of work and examine patients. The new law now allows them to also provide services to other private clinics, private diagnostic or therapeutic laboratories and more generally to all kinds of private businesses, which provide or cover health services, following the granting of a special license by the Senate of their higher education institution. A condition for granting this special permit is their participation in the all-day operation of the hospital, beyond regular hours, at least twice a week outside of on-call days.
3) National Health System hospital transfers
Previously, ESY hospitals could only transfer patients after the completion of their hospitalization (if required) using the public ambulance service (EKAV), free of charge to the patient. A patient could opt to use a private ambulance but had to pay for it out of pocket. The new law now allows ESY hospitals to additionally enter into contracts with the owners of licensed private-sector ambulances to provide this service – also free of charge to patients.
The rationale and potential impact of these reforms
These new provisions significantly alter the existing arrangements and status of doctors employed within ESY. Up to now, all healthcare professionals working in the public sector (for example, hospitals, health centres and rural surgeries) were civil servants and paid a monthly salary. Doctors working in public hospitals were not allowed to practise private medicine, but were permitted to offer care to private patients visiting afternoon outpatient clinics of public hospitals on a fee-for-service basis. Moreover, ESY hospital doctors were previously awarded permanent tenure and a permanent contract after 10 years of service, subject to them successfully passing three consecutive (performance-based) evaluations.
The new law essentially creates three different types of working arrangements:
- Full-time and exclusive employment within ESY (as a salaried civil servant and secure tenure after 10 years)
- Full-time employment within ESY (as a salaried civil servant and secure tenure after 10 years) combined with private practice for additional income
- Part-time employment within ESY as a contracted private practitioner (paid a pro-rata salary) combined with private practice
According to the government, the new provisions intend to motivate doctors to apply for positions that although advertised, are very difficult to fill and to address shortages in the staffing of the public healthcare services across the country. The aim is for the shortage of healthcare workers in the National Health System to be covered through transparent, economically advantageous, contractual relationships with the private sector.
The government opposition, doctors working in public health services and their representatives disagree and argue that the government’s intention is to privatize the National Health System, based on its neoliberal ideology, avoiding its responsibility to strengthen the National Health System by employing permanent healthcare personnel and increasing public health expenditure. The potential negative effects of the new provisions, particularly of dual practice, include:
- an increase in supply-induced demand with the risk of ESY-contracted doctors channelling patients treated in public settings to their private practice for additional services;
- the minimization of the number of services provided in public settings during the day, in order to push patients to make their appointments and undergo scheduled visits and surgeries in private practices and clinics; and
- shifting the cost of healthcare provision to patients who are encouraged or made to shift to receiving services in private settings