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The Risk Watch Column
By Dr Alan Waring
Previous Risk Watch articles have examined major aspects of public health and healthcare in Cyprus, e.g. the costs of an unhealthy nation Parts 1 and 2 in 2010, and the senile dementia epidemic (April 2011). This article considers what has been happening since then regarding the much vaunted Cyprus National Health System, and also more particularly regarding mental health care.
Cyprus NHS – an Elephantine Gestation
On accession in 2004, Cyprus was the only EU Member State not to have an NHS. There were indeed some components of a ‘system’ in place and these were (and still are) generally respected e.g. a mix of state-run and private hospitals and clinics, free or subsidised healthcare for low income and other categories of patient, However, by no stretch of the imagination could it be described as an NHS as conventionally understood and long implemented in other EU Member States. For example, a proper NHS requires national policies, strategies, and standards of excellence on just about every facet of health care provision; the close monitoring and independent auditing of provider units, not just on financial competence and probity but also on management and on clinical care; responsibility and accountability devolved to autonomous provider units; provider units run by professional managers rather than clinical experts; transparency and open publication of reports on individual hospital performance, reorganisation and development plans, and investigations into clinical accidents and maladministration.
However, after so many years talking about, but delaying, setting up an NHS, it was only with the 2013 state bankruptcy crisis and the EU bailout that the Cyprus government found itself bound by a bailout condition on healthcare reforms that required it to establish an operational NHS by 2015.
An early response (2014), assisted by consultants McKinsey & Co, was to draw up a strategy and roadmap. A Health Insurance Organisation was also set up in 2014 to mastermind the Roadmap. The years 2015 and 2016 came and went and still no sign of an NHS. By late March 2017, the government was considering four different funding formulae, all of which involved multi-payers as foreseen in the strategy, and all of which were means-tested as far as patient or employee contributions were concerned.
The Final ‘Gesy’ Decision
In June 2017, the Health Minister announced that the Cyprus NHS would not provide free and universal access to all citizens solely through state-run hospitals and would thus be different to the UK’s NHS, for example, or to the Belgian model whose funding involves citizen payments into a scheme selected from an approved list of insurers, or yet again to the much criticised American free-markets model funded primarily via private insurance. Funding would be via compulsory payments into the scheme at a pre-identified percentage rate of income by employees, self-employed, employers, other income earners and pensioners. The state would contribute an amount roughly comparable to that paid in by the individual employee. Patients would be entirely free to choose their preferred health care delivery provider.
And so, at long last, the new NHS will be phased in from June 1, 2019, with the final phase starting June 1, 2020.
However, apparently, the new funding system covers patient usage only and not capital costs – for example, the building of a new hospital or expansion or modernisation of an existing one, the purchase of state-of-the-art body scanners, or the human resource costs of a major expansion of medical staff. These capital costs will have to continue to be paid for out of Health Ministry budgets funded by general taxation, and therefore represent the biggest stumbling block to meeting the criteria for a proper NHS cited above. In addition, in presenting patients with an absolute freedom to choose a provider, there appears to be no credible national standards-and-performance monitoring system for informing such choices.
State Mental Health Care
Just how mental health care will fare in the new NHS remains unclear. However, Cyprus’s track record to date does not bode well. The European Commission reported in January 2018 that in 2015 the number of psychiatric care beds in Cyprus hospitals was 22 per 100,000 inhabitants compared to an EU average of 72. Cyprus was next to the bottom of the list of 28 Member States. Cyprus’s rate had barely altered from the WHO’s Mental Health Atlas report for 2011, which also noted the virtual non-existence of mental healthcare expertise or provision in primary care facilities.
A WHO/EASP paper in 2016 noted that Cyprus had been strengthening its community-based mental health services, in line with the intentions of the Mental Health Act 1997 to move away from unnecessarily institutionalising mental patients in hospitals. No one could criticise such a commendable objective. However, one only has to consider how particular areas of mental health care have fared under this policy to appreciate that (a) it is not panacea, (b) it may encourage the false idea that mental disorders are primarily social problems, not clinical, and (c) individual patients and their families may suffer.
For example, as reported in Risk Watch in April 2011, the Cyprus Strategic Plan for Alzheimer’s Disease launched by the Health Minister in 2010, has four key elements – three concerning state provision and the fourth on supportive social networks. The case of the celebrated Cypriot artist Thraki Rossidou Jones over five years after developing dementia, and how she and her family were so badly treated by state authorities, serves as an awful example of what happens when state medical authorities regard senile dementia not as a medical condition but as a social problem for which they have no responsibility. All the evidence points to the Cyprus Strategic Plan for Alzheimer’s still relying on voluntary community support without the other three elements of state provision. The number of specialist psycho-geriatric units, and specialist doctors and nurses, will require a major increase to cope with the current and future reality of an ageing population. The state cannot seek to avoid its clinical funding and provision obligations by thrusting such care onto the community and unpaid, unqualified volunteers.
Another example of unintended consequences of an over-emphasis on community-based mental health care is that of patients suffering from psychiatric disorders. Whereas most patients cope on a medicated out-patient basis, some require occasional or intermittent in-patient care following an uncontrolled espisode, while a minority warrant longer-term in-patient care. According to a field study of psychiatric patients in Cyprus published in BMC Psychiatry (Kaite et al, 2016), neither the community-based emphasis nor hospital facilities were functioning as well as desirable. The study reported that patients’ “descriptions of Athalassa psychiatric hospital were as tragic as their concept of the illness” and that one respondent stated “The climate that prevailed in Athalassa […] Little food. Many pills, many injections. I was feeling awful. A ruin, drooling, you were in dirty clothes. Bath? Their bathrooms were ancient. You felt disgusted to have a shower. Yes, even now the situation is very tragic”.
A more recent case (2018) highlights the dangers of the current lopsided state provision when it comes to compulsory admission of a patient undergoing a violent episode into a secure psychiatric unit. The patient’s father summoned the police and his son was taken to Athalassa Hospital pending committal formalities. His son, diagnosed as schizophrenic, stayed in the hospital for several days before release with daily medication and review plan. His father emphasised how impressed he was with the professional care and dedication of the staff at Athalassa, but it was clear that they were operating under very difficult circumstances. He described the physical environment as appalling, with dirty, dilapidated, graffiti-laced rooms, discarded food items, and a general air of a 19th century madhouse. Moreover, patients had little or no means of mental stimulation, except to wander up and down the corridors.
If ever there were an example of an institution needing an urgent injection of state funds for a substantial increase in numbers of qualified staff, support staff, and overall modernisation Athalassa is surely it. However, mental health care clinical facilities across the country also need a huge uplift. But, as the new NHS funding does not address such capital budgets, the Health Ministry really will need to find the money, or else be constantly reminded that their high-minded rhetoric and wonderful strategic plans remain fantasies.
Dr Alan Waring undertook research on the Griffiths and Körner reforms in the UK NHS. His latest book is ‘Corporate Risk and Governance’ from Routledge ISBN 9781409448365. His forthcoming book from Ibidem Verlag (2018) is ‘The New Authoritarianism’ ISBN 9783838211534. Contact [email protected].
©2018 Alan Waring
