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06 September 2024 | Country Update
Reform of psychiatric and mental health services in Greece -
06 September 2024 | Policy Analysis
New legislation for the reform of psychiatric services in Greece proves to be controversial -
26 September 2023 | Policy Analysis
Greece introduces a new 10-year National Action Plan for Mental Health to reform the provision of mental health services -
26 September 2023 | Country Update
Greece releases its National Action Plan for Mental Health -
26 April 2019 | Country Update
Assisted living shelters are designed to enhance the social integration of people with disabilities
5.11. Mental health care
Since the establishment of ESY in 1983, four milestones stand out in mental health care (Chondros & Stylianidis, 2016; Giannakopoulos & Anagnostopoulos, 2016). The first period from 1984 to 1990, in accordance with European Regulations 815/84 and 4130/88, saw the training of mental health professionals; the creation of a decentralized community network of preventive, specialized treatment and rehabilitation services; the deinstitutionalization of patients in psychiatric hospitals and a reduction in admissions to psychiatric hospitals. The second milestone revolved around the reform projects Leros I and II (1990–1994), which introduced interventions to improve conditions in the Leros Mental Hospital and discharge patients to placements in community hostels. The third milestone was the introduction of progressive legislation on the development and modernization of mental health services (Law 2716/1999). The legislation established sectoral mental health committees and created infrastructure in the community, including psychiatric departments in hospitals, mental health centres, child guidance centres, day care centres, home care services, vocational training workshops, mobile units, social cooperatives as a tool for increasing working opportunities for people with mental illness and crisis management units.
The fourth and most significant milestone for the deinstitutionalization of mental health services and the development of community-based services were the Psychargos I (1997–2001) and II (2001–2010) programmes. Priority was given to social inclusion, social cohesion and destigmatization. The main objective was the development of services within the community that would enable patients to be supported within their own family environment, maintaining their social activities through every possible means. Particular policies focused on prevention and rehabilitation, the restructuring and strengthening of primary health care, ambulatory care, deinstitutionalization and closure of psychiatric hospitals, psychosocial rehabilitation and housing services, continuity of care and harnessing voluntary assistance from the community for the promotion of mental health.
An ex-post evaluation of the Psychargos programme using qualitative methods reported a number of positive as well as negative elements of the reform (Loukidou et al., 2013a). The positive aspects were:
- the reduction of hospital-based long-stay accommodation;
- the vast increase in the number of new mental health services across the country, including day centres, community mental health centres, psychiatric units in general hospitals and children’s mental health centres;
- positive changes in public attitudes towards mental illness and patients as well as in the attitudes of mental health staff towards person-centred care;
- the empowerment of service users to express themselves and to defend their rights by participating in mental health organizations and institutions; and
- increased opportunities for vocational training of service users through the establishment of social enterprises and paid work.
The negative aspects include:
- the significant shortages of staff and services in several parts of the country, particularly in rural areas, resulting in inequities in the development of services between different areas and inadequate provision on the ground;
- incomplete sectoral framework and the lack of coordination between mental health services and central government, local authorities, social services and other relevant public sector organizations;
- absence of evaluation and monitoring of provided services, quality assurance and clinical governance systems;
- deinstitutionalized patients resettled in community services representing only a small proportion of people suffering from mental ill health, with a larger number of people still living with their families, homeless, in poverty or ending up in private clinics where the quality standards are questionable;
- gaps in specialist mental health services, such as those for children, adolescents, autistic spectrum disorders, intellectual disabilities, eating disorders and forensic psychiatric services;
- lack of information about locally available services and poor information flow between different services;
- lack of thoughtful planning and implementation;
- only partially achieving the aim to introduce psychiatric services in general hospitals; and
- lack of a population-based approach to the mental health system, without clear evidence for assessing the needs of local populations and no clear understanding at the local level of what components are necessary for a comprehensive system of care.
Furthermore, a quantitative evaluation of the achievement rate of the targets set in the Psychargos programme revealed its strengths and weaknesses (Loukidou et al., 2013b). Positive developments were the closure of five mental hospitals and exceeding the target number of sheltered apartments by 211%, Alzheimer’s centres by 180% and day centres by 95%. In contrast, negative developments were the limited capacity of the over 60 NGOs providing mostly residential and day care, and the fact that boarding houses achieved 89% of the target, sociovocational rehabilitation units reached 69% of the target, outreached teams achieved 68% of the target, general hospital psychiatric and child psychiatric units reached 55% of the target, guest houses achieved 52% of the target, community mental health centres reached 43% of the target, and social enterprises reached only 33% of the target. None of the projected drug and alcohol abuse centres was established.
In view of the findings of the external evaluation of Psychargos I and II, in November 2011 the Greek Government launched the Psychargos III programme to continue strengthening mental health care reforms until 2020 (Ministry of Health and Social Solidarity, 2011b). The new plan is based on three pillars:
- actions for the further development of mental health structures in the community at the sectoral level (territorial sectors based on geographical and population characteristics) with allocation of available mental facilities to provide mental health services to a defined catchment area;
- actions for the prevention and promotion of the mental health among the general population; and
- actions that would organize the psychiatric care system, including sectoral allocation of services, monitoring, evaluation, research activities and training of staff.
A recent law on the administrative reform of mental health services passed in March 2017 provides for the establishment of a number of scientific and administrative committees, councils at both regional and sectoral levels and coordination bodies in order to achieve better coordination of mental health services, greater participation of citizens in mental health policy decision-making, and the protection of the rights of the users of mental health services.
Table5.5 gives an overview of the mental health workforce, availability of services and uptake for 2014.
Table5.5
Funding difficulties and staff shortages during the current financial situation and austerity measures raise serious concerns over the continuation of mental health policy reform and the risk that the positive improvement achieved so far may be halted or even reversed (Ploumpidis, 2015). In addition, the persistent recession in Greece has had negative socioeconomic consequences, which, in turn, have impinged on the mental health of the population. The growing mental health needs of the population in tandem with the limited available resources raise the key question of whether existing mental health services are capable of addressing the increasing demand for mental care (Economou et al., 2016c).
In July 2024, the Greek parliament passed legislation (Law 5129/2024 for the “Completion of the psychiatric reform”) to reform the structure and governance of Greece’s mental health institutions, therapy centres and drug and alcohol rehabilitation programmes.
The three main changes introduced are:
- The establishment of a legal entity, the National Network of Mental Health Services, which attempts to unify into a single network all the mental health units of the National Health System (NHS) and private psychiatric clinics, together with NGOs. The National Network is structured into Regional Networks of Mental Health Services, operating in the Directorates of Health Regions and managed by the Deputy Governor of the relevant Health Region.
- The establishment of a non-profit legal entity of private law under the name “National Organization for the Prevention and Treatment of Addictions”, to which all the organizations, units and addiction programmes in the country will belong. The National Organization will have its headquarters in Athens.
- The establishment of a Register of Mental Health Units of legal entities under private law.
Authors
References
Policy context and impetus for the reform
Based on the 10-year National Action Plan for Mental Health (2021–2030) introduced in March 2023 by the Ministry of Health containing policies and interventions for the promotion, protection and enhancement of mental health for the population, Law 5129/2024 for the “Completion of the psychiatric reform” was passed in July 2024. The aim of the new law is to reform the structure and governance of Greece’s mental health institutions, therapy centres and drug and alcohol rehabilitation programmes.
Content of the reform
The three main changes introduced are:
a) The establishment of a legal entity of private law under the name “National Network of Mental Health Services”, which attempts to unify into a single network all the mental health units of the National Health System (NHS) and private psychiatric clinics, together with NGOs.
The National Network of Mental Health Services is structured into Regional Networks of Mental Health Services, operating in the Directorates of Health Regions. These Regional Networks are managed by the Deputy Governor of the relevant Health Region, which is responsible for mental health issues.
(b) The establishment of a legal entity of private law under the name “National Organization for the Prevention and Treatment of Addictions”, to which all the organizations, units and addiction programmes in the country will belong. The National Organization will have its headquarters in Athens.
(c) The establishment of a Register of Mental Health Units of legal entities under private law.
Reactions to the reform
The legislation has caused controversy and protests from unions and people working in public health services. One of the main objections is that the measures contained in the Law do not directly address the chronic underfunding and understaffing of public mental health and psychiatric services delivered by the NHS. The other concern is over potential moves towards privatization.
Media reports highlight that according to the Pan-Hellenic Federation of Professionals in Public Hospitals the reform “will serve to further dismantle the already crippled public mental health care system by abolishing and centralizing existing local units, which will lead to the privatization of services” and to non-profit organizations undertaking some service in an ineffective way (Tovima, 2024; The National Herald, 2024).
The Federation’s response reflects strong objections to putting all NHS mental health units under the jurisdiction of the relevant Regional Health Authority, under a single Directorate covering medical, nursing and mental health services. In theory, this kind of centralization would allow the Deputy Governors of the Health Regions (who are appointed by the Minister of Health) to close public units in order to give space to private providers. A further concern is that the intention of the new law is to give more space to NGOs and private clinics by channelling funding from the EU Recovery and Resilience Fund to them (Health Daily, 2024).
Authors
References
Health Daily (2024) “No to Mental Health draft bill from all mental health and addictions workers”, 15 July 2024 (in Greek), https://healthdaily.gr/2024/07/15/ochi-sto-s-n-gia-tin-psychiki-ygeia-apo-to-synolo-ton-ergazomenon-stin-psychiki-ygeia-kai-stis-exartiseis/
Law 5129/2024, “Completion of the psychiatric reform”. Official Government Gazette, Issue A’/Number 124/01-8-2024 (in Greek), https://www.et.gr/api/DownloadFeksApi/?fek_pdf=20240100124)
The National Herald (2024) “Greece’s Mental Health Reforms Draw Protests from Union, Doctors”, 30 July 2024, www.thenationalherald.com/greeces-mental-health-reforms-draw-protests-from-union-doctors
Tovima (2024) “Debate Over Greek Government’s Mental Health Reform Bill Heats Up”, 29 July 2024, https://www.tovima.com/politics/debate-over-greek-governments-mental-health-reform-bill-heats-up
Context
In March 2023, the Ministry of Health presented the National Action Plan for Mental Health, a 10-year action plan (2021-2030) which was designed by a 35-member expert committee in collaboration with the World Health Organisation.
Main purpose of the National Action Plan
The plan involves policies and interventions for the promotion, protection and enhancement of mental health for all citizens and especially for vulnerable groups and aims to ensure universal access in mental health services and eradicate stigma and social exclusion. The overall objective is to achieve deinstitutionalization by establishing an integrated holistic, recovery-oriented, community-based mental health services system.
Content
The Plan is developed in five vertical and five horizontal intervention axes:
Vertical axes
- Completing the abolition of institutional care, abolition of the departments of chronic patients in the remaining psychiatric hospitals of the National Health System, with the parallel development of services for people with Alzheimer’s disease and related disorders as well as the development of psychogeriatrics.
- Further development and integration of the community network of mental health services, emphasizing prevention with simultaneous integration of mental health services in primary health care, utilizing modern digital technologies.
- Completing the network of mental health services for children and adolescents, with an emphasis on prevention, including special provision for individuals with Pervasive Developmental Disorders (autism spectrum disorders).
- Reform of forensic psychiatric services from institutional to community services and the development of Psychiatric Intensive Care Units.
- Completing and strengthening of the nationwide network of Limited Liability Social Cooperatives, which are social enterprises whose aim is the socio-economic inclusion and professional (re)-integration of people with psychosocial difficulties, contributing to their therapeutic rehabilitation and, as far as possible, to their self-sufficiency.
Horizontal axes
- Achieving “sectorization” across the country (that is, establishing small geographical catchment areas with dedicated mental health staff providing services to all patients living in the area), taking into account all the pillars of mental health services provision (public and private sector, non-profit civil partnership), ensuring the quality and safety of the recipients of mental health services and promoting research and training in mental health. The aim is to decentralise decision-making and to develop local mental health services with greater autonomy and local leadership potential.
- Reducing the number of involuntary hospitalizations to the EU average.
- Promoting the integration of people with mental health problems in the labor market and developing programs to protect the mental health of employees.
- Protecting the rights of the mentally ill and combating social stigma, while empowering the voice of the mentally ill and their families.
- Strengthening mental health services in the planning of dealing with emergency events such as the COVID-19 pandemic or natural disasters.
Implementation
Authors
References
In March 2023, the Ministry of Health introduced the National Action Plan for Mental Health, a 10-year action plan (2021–2030) containing policies and interventions for the promotion, protection and enhancement of mental health for the population, and especially for vulnerable groups. It aims to ensure universal access in mental health services and eradicate stigma and social exclusion. The overall objective is to achieve deinstitutionalization, by establishing an integrated holistic, recovery-oriented, community-based mental health services system.
See the Policy Analysis on this topic for more details.
Authors
References
New legislation in April 2019 establishes assisted living
shelters for people with disabilities over the age of 18. The shelters
aim to support residents to participate in the daily life of their
communities and to manage their personal lives with independence and
autonomy. In line with the deinstitutionalization of care, these new
residential arrangements recognize the abilities of disabled adults and
their right to live with equality and dignity in the community. They
also aim to improve quality of life, support participation in
educational programmes, and foster social rehabilitation and
integration.
Assisted living shelters provide a healthy,
comfortable and safe place to live; healthy and balanced meals;
entertainment and participation in social events; access to health care
services as well as to life-long learning programmes, training and
employment; and help with developing the personal skills and capacities
needed to achieve autonomy and social integration.
Legislation
Joint
Ministerial Decision No D12/GPoik.13107/283, Prerequisites for the
establishment and functioning of Assisted Living Shelters for people
with disabilities.