Greece has a hybrid healthcare system in which the public sector offers universal care free at the point of access. The public sector plays a crucial role, especially in rural areas of the country. In cities, the public sector serves the majority of the population but the private sector has a strong presence. The third sector has a patchy – but very useful – presence, especially in tackling problems in remote areas and specific issues (for example, the refugee crisis). Primary care is not uniformly developed in Greece and therefore people often refer themselves to secondary or even tertiary care directly.
Mental healthcare in Greece is undergoing a prolonged period of reform. Significant progress has been made in recent decades, especially in the context of the Psychargos programmes, but there is still a lot to be desired. Deinstitutionalisation has largely taken place as many large psychiatric hospitals have now been decommissioned and replaced by smaller, community-integrated placements. Community care has developed in some areas, but its wide implementation is hampered by financial and systemic issues. These systemic issues are mainly evident in the degree of strategic coordination and the relative imbalance of services developed in different areas. The sectorisation of mental health services represents an ongoing effort to decentralise decision-making. This is backed by evidence suggesting that Greece has both the need for the development of local mental health services with greater autonomy and local leadership potential. Advocacy and representation have almost universal support, but are not yet widely formalised. Progress is slowly being made in the areas of quality assurance and clinical governance, and more formal professional revalidation processes are being planned. Mental health often compensates for social care and there is an effort to centre care on prevention (Christodoulou et al, Reference Christodoulou, Ploumpidis and Christodoulou2010; Loukidou et al, Reference Loukidou, Mastroyannakis and Power2013).
Current challenges for Greek psychiatry
There are a number of challenges for psychiatry in Greece at present, but ultimately challenges can be traced back to two factors: economic and organisational.
Organisational factors are chronic and present in Greek society as a whole; but they cluster together with many positive attributes such as perseverance, resilience, ingenuity and independence. The mirror image of these virtues has yielded a complex system which sometimes seems resistant to change. Pragmatically, this translates into day-to-day impracticalities in the professional lives of psychiatrists, which range from issues with communication and prescribing to longer-term issues such as career planning and professional development. Professional revalidation and continuing professional development are especially pressing needs for which the Hellenic Psychiatric Association must assume active leadership.
Organisational issues have been further complicated by the ongoing economic crisis and the refugee crisis. Regarding the latter, providing effective mental healthcare for refugees, local inhabitants and refugee workers is still a challenge despite non-governmental and volunteer organisations – among others – complementing the actions of the Greek State. Refugees in Greece theoretically have access to social welfare, public healthcare and public education; but, in practice, access is limited due to overwhelmed resources and capacity (Anagnostopoulos et al, Reference Anagnostopoulos, Giannakopoulos and Christodoulou2017). Partly due to its synergy with (a) a struggling social care system, (b) the overwhelmed public health sector and (c) the refugee crisis, mental healthcare was actually affected disproportionately during the economic crisis despite spending remaining at 0.16–0.19% of gross domestic product. This affected the mental health of the population, mental health services and psychiatry as a whole (Christodoulou & Christodoulou, Reference Christodoulou and Christodoulou2013; Anagnostopoulos et al, Reference Anagnostopoulos, Giannakopoulos and Christodoulou2016). The system was already underfunded and struggling with levels of staffing (Christodoulou et al, Reference Christodoulou, Ploumpidis and Christodoulou2010). It was not prepared to cope with such an economic hit, which yielded an acute-on-chronic crisis (Hyphantis, Reference Hyphantis2013). The rate of psychiatric reform has also been hampered by the persisting economic crisis as imposed austerity measures have dictated other priorities. The financial crisis has affected psychiatrists themselves, who are left to cope with tight personal finances and an increasingly pressured system.
Coping with pressure and looking forward
Psychiatrists and other mental health professionals in Greece deserve kudos for operating under considerable difficulties, which are undoubtedly contributing towards burnout and have stifled progress. However, as some of those difficulties are manageable, there is scope for optimism. The effects of the recent economic crisis on society and psychiatry may serve as an incentive to identify opportunities for attitudinal change (Christodoulou, Reference Christodoulou2017).
In our view, preventive psychiatry is an ideal response for both the economic and the organisational problems facing Greek psychiatry today. Preventive psychiatry entails all those policies and strategies that aim to prevent mental illness and promote mental health. It forces longitudinal planning over rash measures and therefore tackles Greece's organisational conundrum, while at the same time representing the most cost-effective way to run mental health services in the medium to long term, thus tackling the economic question. Preventive psychiatry also results in greater collateral health and economic gains for society as a whole (Kalra et al, Reference Kalra, Christodoulou and Jenkins2012). Initiatives in Greece that practically endorse illness prevention and health promotion include the Local Healthcare Groups (‘ΤΟΜΥ’), which are recent initiatives meant to facilitate primary healthcare provision. In addition, in secondary/tertiary care, the development of early intervention services has shown promising results in Greece, and plans exist for further development of an early intervention referral network (Kollias et al, Reference Kollias, Xenaki and Dimitrakopoulos2016).
Another vital response to Greek psychiatry's organisational and economic challenges is the continued investment in its psychiatric reform (Christodoulou et al, Reference Christodoulou, Ploumpidis and Christodoulou2012; Christodoulou & Anagnostopoulos, Reference Christodoulou and Anagnostopoulos2013). This should be done in an evidence-based way, guided by lessons learned from reforms of systems elsewhere in the world, to avoid issues such as excessive bed closures, private sector over-involvement, insufficient community services, etc. There is good evidence suggesting that patients’ unmet health needs are affected primarily by financial factors and we also know that the principal healthcare provider (i.e. the public sector) is struggling with understaffing and underfunding. It would seem that rational investment in the continued psychiatric reform – and in particular in the public sector – would be a logical way forward.
Conclusion
Despite challenges from significant recent crises and its own chronic issues, Greek psychiatry is developing in the right direction. We suggest that preventive psychiatry, continued psychiatric reform and investment in the public health sector represent the best strategies towards a sustained solution to the challenges faced by Greek psychiatry.
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