2.5. Patient empowerment

2.5.1. Patient information

All institutions under the Ministry of Health have their own publicly accessible websites, as do YPEs and EOPYY. The information available on these websites includes mainly statutory benefits, the range of services provided, and location and availability of public and private providers contracted with EOPYY. Those insured under EOPYY also have access to their personal medical records via a web application located within EOPYY’s site. Furthermore, 24/7 telephone information is available for many public services and NGOs providing psychosocial or other support for those suffering from disorders such as drug addiction, HIV/AIDS, psychological problems or cancer. Information for ethnic minorities and translations into minority languages concerning health service facilities and legal issues about migrants’ rights to access health care are also available, although limited, on NGOs’ websites and sites developed as a result of research projects.[3] There is no information accessible to patients on costs or quality of services, medical errors, patient satisfaction, hospital clinical outcomes, hospital waiting times or comparative information about the quality of different providers (Table2.3).

Table2.3

2.5.2. Patient choice

In general, patient choice refers to choice of insurer, choice of provider and choice of treatment. In Greece, individuals do not have choice of insurer; for SHI, it is compulsory for all of the employed population to be insured under EOPYY. Instead, there is a large degree of choice of provider (Table2.4). Patients can receive services at any PEDY primary health care unit (and their contracted providers) or at outpatient departments of public hospitals that provide ambulatory care. The introduction (in 2001) of afternoon outpatient clinics in public hospitals, where doctors offer care to private patients on a fee-for-service basis, increased the choice of specialists, albeit to those with sufficient income to afford it. In addition, given that a referral system has not yet been established, patients can choose any public hospital to undergo hospital treatment.

Table2.4

One important limitation to patient choice should be highlighted, however. In the context of the health reforms introduced after 2010, (monthly) ceilings have been imposed on the activities of doctors contracted with EOPYY, including the number of patient visits, number of pharmaceutical prescriptions and number of diagnostic and laboratory tests prescriptions (section 6.1). As a consequence, patients may need to contact several doctors in order to find those who have not reached their visit and prescription limits. Theoretically, patients can opt for a second opinion, given that there are no restrictions concerning the choice of hospital. Nevertheless, their choice is conditional on their access to information about costs and quality of services, which is very limited.

2.5.3. Patient rights

Rights

Prior to 1992, patient rights in Greece were indirectly addressed through relevant provisions in civil, penal, administrative and disciplinary law, in the Code on the Practice of Medicine and the Code on Medical Deontology. In 1992, broader health care reform legislation directly addressed the rights of hospital patients and in 1997 further provisions extended the rights of patients to primary health care (Merakou & Tragakes, 1999; Goffin et al., 2007).

More specifically, under article 47 of Law 2071/1992 (Table2.5), patients have the right to:

Table2.5

• access the most appropriate hospital services for the condition suffered;
• receive care (widely defined) with due respect for their dignity as human beings;
• give or refuse consent to any diagnostic or therapeutic procedure (if a patient is suffering from total or partial mental incapacity, the exercise of this right shall devolve to the person legally acting on his or her behalf);
• request information regarding their personal situation;
• act in their own interests and make informed decisions, or participate in any decision-making likely to affect their own lives subsequently, with a guarantee that the information provided to them is comprehensive (encompassing medical, social and financial aspects) and accurate;
• be thoroughly informed in advance of any risk likely to arise as the result of unusual or experimental diagnostic or therapeutic procedures, such procedures only being performed with the patient’s consent, which may be withdrawn at any time;
• feel that they are entirely free to decide whether or not to consent to collaborate for the purposes of research or training, and such consent may be withdrawn at any time;
• have their private life protected, with confidentiality guaranteed with regard to the data and content of documents concerning each patient and also with regard to the file in which any observations or medical findings are recorded;
• have their religious and ideological convictions respected and acknowledged; and
• be able to present and submit, in an appropriate manner, any complaints and objections and to be fully informed of the effects and outcomes thereof.

Law 2719/1999 on the development and modernization of mental health services provides for the protection of the rights of people with mental health disorders. It also established within public hospitals an Office of Communication with Citizens, which contains a committee for the promotion of patient rights.

Greece has also signed and ratified the Council of Europe’s Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine (Garanis-Papadatos & Dalla-Vorgia, 2003). A National Bioethics Committee under the jurisdiction of the Prime Minister was established in 1998 as an independent advisory body of experts for public authorities. Last but not least, in 2005 a new Code of Medical Ethics replaced the old Code, which dates back to 1955. The new Code is consistent with international documents on medical ethics, such as the Geneva Declaration, the Oviedo Convention and the World Medical Association International Code on Medical Ethics (Goffin et al., 2007).

Complaints

In 2004, the Ombudsman for Health and Social Solidarity was established. The Ombudsman investigates complaints regarding individual administrative actions or omissions or material actions taken by public health care services that infringe upon the personal rights to health or violate the legal interests of individuals or legal entities.

Other avenues for pursuing complaints date back to 1997 and use the Ministry of Health’s Independent Service for the Protection of Patients’ Rights, which was under the jurisdiction of the Secretary General of Health. This service monitors developments in patient rights and receives, classifies and follows up complaints by citizens who feel their rights as patients have been violated. These complaints are submitted to the Committee for Regulation of Protection of Patients’ Rights, which is composed of a representative of the Legal State Council and representatives from professional, scientific and social groups, as well as trade unions. The Committee monitors health service compliance with patient rights and regulations and follows up on patients’ complaints. Once a decision is made by the Committee regarding the accuracy of a complaint, it submits its conclusions to the General Secretary of the Ministry of Health, who will ensure that all necessary or corrective actions are implemented. Where there is evidence of a penal infraction, the case is transferred to the relevant prosecuting authority.

Medical errors

There are two dimensions of liability in Greece with regard to medical errors: disciplinary and legal. The medical associations, the regional disciplinary councils and the Central Disciplinary Council of the Ministry of Health are responsible for disciplinary regulations. Punishments imposed by these bodies range from a suspension to final expulsion from the profession. Legal liability refers to the competence of the courts; if a doctor is found guilty, the sentence may be imprisonment or economic compensation for the patient. Specific regulations or initiatives to prevent health care-related harm have not been adopted. For example, Greece has no central national authority to collect reports of medical errors; most adverse events are detected using spontaneous reporting, which identifies only a small number of adverse events.

Rights awareness

Initial studies conducted at the beginning of 2000 indicated that the vast majority of patients (84.3%) had no knowledge of their rights provided under legislation (Merakou et al., 2001). More recent studies show that the situation has improved. According to the results of a survey conducted in 2010, in a sample of 500 patients from two public hospitals, 66.3% had knowledge of their rights (Koulizos et al., 2012). Nevertheless, many other patients failed to recall major aspects of their rights (Falagas et al., 2009).

2.5.4. Patients and cross-border health care

In Greece, the demand for cross-border health care is regulated by EOPYY. In addition, as EU members, Greek citizens are entitled to health care according to European Commission regulations on the coordination of social security systems. If a Greek citizen unexpectedly needs treatment while travelling in an EU Member State, the European Health Insurance Card ensures that the cost of treatment is covered. Prior authorization from EOPYY is required for coverage of the expenses of planned hospital care (in accordance with Directive 2011/24/EU on patient rights in cross-border health care). More precisely, EOPYY requires prior authorization for health care that involves overnight hospital accommodation of the patient for at least one night, or requires use of highly specialized and cost-intensive medical infrastructure or medical equipment, or involves treatments presenting a particular risk for the patient or the population.