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21 January 2025 | Country Update
New law revises the implementation of the “personal doctor” and introduces the “personal paediatrician” in primary care -
21 January 2025 | Country Update
Financial incentives are introduced for young doctors to specialize in general medicine -
21 January 2025 | Policy Analysis
New Law reforms the function of the “personal doctor” in primary care
5.3. Primary / ambulatory care
Ambulatory care in Greece is delivered by a mix of public and private health service providers. There are three main modes of delivery:
- provision through the ESY, including the National Centre for Emergency Care (EKAV; section 5.5), rural health centres and their health surgeries and public hospital outpatient departments (section 5.4.1);
- provision through local authorities and NGOs, including clinics and welfare services offered free of charge by municipalities and civil society organizations, which are limited in scope, covering only a narrow range of care and are used primarily by uninsured people and (particularly) by refugees and migrants; and
- provision by the private sector, including medical offices, laboratories, diagnostic centres and outpatient medical consultations at private sector hospitals, which is financed by direct payments or private insurance but may be contracted by EOPYY.
The transfer of all ambulatory care networks operated by the sickness funds to EOPYY in 2011 constituted a major restructuring of ambulatory care (e.g. the large network of approximately 350 polyclinics belonging to IKA ATHINON (IKA), the largest fund and covering white and blue collar workers, were transferred to the ESY). In addition to being the sole purchaser of health services, EOPYY became an ambulatory care provider. A subsequent reorganization of primary care in 2014 (Law 4238/2014) placed all EOPYY ambulatory-care facilities, rural health centres and their surgeries under the jurisdiction of YPEs and their PEDYs (Chapter 2). The aim was for these facilities to function 24 hours a day, seven days a week. In addition, the Law provides for the establishment of a referral system based on family GPs, although it has not yet been implemented. A gatekeeping system does not exist as yet and almost all primary care providers are specialists: according to data from the Hellenic Statistics Authority, in 2014, out of a total of 68 807 doctors, only 2626 (3.8%) were GPs.
Ambulatory care in rural and semi-urban areas is mostly delivered by a network of 205 health centres staffed with GPs and specialists (paediatricians, gynaecologists, orthopaedists, ophthalmologists, urologists, dentists, general surgeons, psychologists, radiologists, physiotherapists, microbiologists, nurses, midwives and social workers). In addition, approximately 1700 rural health surgeries that are administratively linked to health centres are staffed with publicly employed doctors and medical graduates. The latter are required to spend at least one year in a rural area upon graduation and prior to enrolling for medical specialization. The number of available doctors in each health centre depends on the characteristics of the catchment area (e.g. size, economic growth, epidemiological profile and access to hospital).
Each health centre covers the health needs of approximately 10 000 to 30 000 people, operating on a 24-hour basis and includes consultation rooms, rooms for one-day medical treatment, basic diagnostic equipment, radiological and microbiological laboratory, septic surgeries, dental clinics and an ambulance. This infrastructure contributes to the provision of a wide range of services, which include prevention (mainly immunization) and health promotion, emergency services, first aid and transportation, diagnosis, cure, dental treatment, pharmacy services and prescribing, rehabilitation and social care; as well as epidemiological research and training of medical personnel. Health centres are also involved in school hygiene services, occupational health services, family planning and prenatal care. In addition, centres provide short-stay hospitalization and follow up care for recovering patients. Visits to health centres are now free of charge (although a €5 user charge was imposed between 2011 and 2015). Table5.1 presents the regional allocation of health centres as well as their staffing and equipment.
Table5.1
In addition to public ambulatory care services, there are more than 22 000 private practices, over 13 000 private dental practices and approximately 3527 private diagnostic centres. Most are equipped with high-quality and expensive medical technology. The majority of private facilities are located in Athens and Thessaloniki. EOPYY contracts private practices, laboratories and diagnostic centres to provide health care services to those insured. It also provides services directly to patients on a fee-for-service basis, paid directly by patients or through private insurance. Rehabilitation services and services for elderly people are predominantly offered by the private sector (Economou, 2015).
With demand increasing in the public health system, there is a growing role for municipalities, NGOs (through community clinics and pharmacies) and other unofficial networks of health professionals and volunteers designed to help poor and uninsured patients. These services contribute significantly to securing access to a basic set of medical services among poor and unemployed people. A network of around 40 community clinics operates across Greece, offering mostly medications and primary health services free of charge to people unable or ineligible to use public services and provided mainly by GPs, cardiologists, paediatricians, gynaecologists, dentists and opticians (section 2.1).
Since 2014, a system of monthly caps has operated on physician activity. Every doctor contracted with EOPYY has a limit of 200 visits per month (Ministerial Decision No. Y9a/oik.37139 of 9 May 2014) and there are also a monthly ceiling on the value of pharmaceutical prescriptions (Ministerial Decision No.Y9/oik.70521 of 18 August 2014). The latter varies according to specialization, number of patients prescribed for, the prefecture and the month of the year (seasonality). This means that those insured with EOPYY who are in need of a doctor’s visit or a prescription must either find a physician who has not reached the ceiling or they will have to pay out of pocket.
The need to establish an integrated primary care system was not on the health reform agenda during the 2000s and of the many proposals submitted by the scientific community, none was ever implemented (Box5.2).
Box5.2
At the time of writing (2017), a new Primary Care Plan had been formulated by the Ministry of Health, with implementation envisaged over three years. The first axis of the new system will be the establishment of a national, decentralized, community-oriented network of local primary care units, staffed with multidisciplinary teams (e.g. doctors, nurses, social workers) that will be the first contact point within the health system. The second axis will consist of health centres functioning as reference points for required specialized and diagnostic ambulatory services, thus integrating care (Box5.3 and Chapter 6). A project aimed at providing integrated health and social services and funded by the joint European Commission and WHO Regional Office for Europe grant is currently being piloted in the city of Ioannina with a population of 120 000 and two general hospitals (WHO Regional Office for Europe, 2017).
Box5.3
New legislation (Law 5157/2024) introduced on 15 November 2024 aims to increase access to publicly reimbursed primary, preventative and health promotion services by expanding the pool of doctors who can become “personal doctors”. Previously, only doctors who served in public primary healthcare facilities, or private doctors contracted with the National Organization for the Provision of Health Services (EOPYY), could take on the duties of a personal doctor. Now, rural doctors and all private general practitioners or internists, regardless of whether they are contracted with EOPYY, qualify for the role.
The personal coctor is designed to be the first point of contact for their patients, to guide them through the National Health System and to provide a gateway to health services. Registration with a personal doctor is mandatory for all adults. Citizens who do not voluntarily register with a personal doctor by 1 June 2025 will be automatically enrolled. The Law also introduces the function of “personal paediatrician” for optional registration of children under the age of 16. In the first phase, free access to a personal paediatrician will be provided to approximately 530 000 children.
Further information is provided in the Policy Analysis “ New Law reforms the function of the ‘personal doctor’ in primary care” (21 January 2025) on this platform.
Authors
References
Authors
References
Policy context and impetus for the reform
Since 2017, Greece has been working to strengthen primary care through expanding the national network of local health units (TOMYs) and health centres. In tandem, and as part of the wider aim to increase access to publicly reimbursed community-level primary, preventative and health promotion services, the role of the “personal doctor” was introduced in May 2022 (Law 4931/2022). The “personal doctor” is designed to be the first point of contact within the health system, to guide their patients through the National Health System and to provide a gateway to health services.
The 2022 law stipulated that the personal physician was to be selected by individuals, and the choice could be made either with doctors who served in public primary health care facilities, or with private doctors contracted with the National Organization for the Provision of Health Services (EOPYY), the purchaser of publicly funded health services. Although the initial law underwent various amendments during the following two years, the new system never became fully operational since the number of doctors in public facilities was not sufficient to cover the needs of the population and private doctors appeared less interested and unwilling to sign contracts with EOPYY.
Consequently, on 15 November 2024, the government passed new legislation (Law 5157/2024) bringing in reforms with the aim of expanding the pool of personal doctors and to generally upgrade this function.
Content of the reform
The new law introduces the following provisions:
- The pool of personal doctors is expanded to include rural doctors and private general practitioners or internists. More specifically, the rural doctor service, commonly known as the “agrotiko,” is abolished, and these positions become mandatory personal doctor roles. New doctors will be required to provide personal doctor services to the local population they cover. In relation to private doctors, until now, personal doctor were chosen from specific categories of doctors, either contracted with EOPYY or designated as personal doctors within the publicly funded health system. Citizens are now allowed to choose a private doctor not contracted with EOPYY as their personal doctor, but they will pay for these services out of pocket. Furthermore, according to the new law, even doctors contracted with EOPYY as personal doctors have the right to offer additional personal doctor services privately, and are compensated directly by patients, serving up to 500 additional citizens.
- The function is extended to minors with the introduction of the “personal pediatrician”. Registration with a pediatric personal doctor for children under the age of 16 is optional.
- The registration system has changed. Registration with a personal physician remains mandatory for all adults. However, the disincentive framework that was previously in place and which imposed penalties on citizens for not registering with a personal doctor has been abolished. This framework had not been implemented due to the insufficient number of doctors available for the entire population. Instead, the new legislation provides for citizens who do not voluntarily register with a personal doctor by 1 June 2025 to be automatically enrolled by the electronic system of the e-Government Center for Social Security (IDIKA).
- Financial incentives are provided for young doctors who decide to undergo training in general/family medicine and internal pathology, up to EUR 40 000 as a one-off grant. These newly qualified physicians will be required to serve as personal doctors within the primary care system.
In addition, as part of a bundle of other measures to strengthen access to primary care, the new law foresees the conversion of 8 health centres into university health centres, offering services like telemedicine, preventive medicine, and public health research, while also serving as training hubs for primary healthcare professionals. These university health centres will be affiliated with the designated university medical schools and staffed by faculty members.
Authors
References
Law 4931/2022, “Doctor for all, equal and quality access to the services of EOPYY and Primary Health Care and other emergency provisions”. Official Government Gazette No 94/Issue A’/13-5-2022.
Law 5157/2024, “Reform of the institution of the Personal Physician – Establishment of University Health Centers – Disability pension due to common disease and other provisions”. Official Government Gazette No 187/Issue A’/15-11-2024.
Athens News (2024) A personal doctor for every Greek citizen and a free pediatrician – we discuss a new bill, 25 September 2024. https://en.rua.gr/2024/09/25/a-personal-doctor-for-every-greek-citizen-and-a-free-pediatrician-we-discuss-a-new-bill
Athens Times (2024) Personal doctor: Optional registration for under 16 – What the bill provides, 29 October, 2024. https://athens-times.com/personal-doctor-optional-registration-for-under-16-what-the-bill-provides
Protothema (2024) Ministry of Health: Three changes to the Personal Doctor system – When patients will have to pay, 13 November 2024. https://en.protothema.gr/2024/11/13/ministry-of-health-three-changes-to-the-personal-doctor-system-when-patients-will-have-to-pay