Reengineering NHS Hospitals in Greece: Redistribution Leads to Rational Mergers

The purpose of this study was to record and evaluate existing public hospital infrastructure of the National Health System (NHS), in terms of clinics and laboratories, as well as the healthcare workforce in each of these units and in every health region in Greece, in an attempt to optimize the allocation of these resources. An extensive analysis of raw data according to supply and performance indicators was performed to serve as a solid and objective scientific baseline for the proposed reengineering of the Greek public hospitals. Suggestions for “reshuffling” clinics and diagnostic laboratories, and their personnel, were made by using a best versus worst outcome indicator approach at a regional and national level. This study is expected to contribute to the academic debate about the gap between theory and evidence based decision-making in health policy.


Introduction
In the health sector, the task of reorganizing two or more hospitals in an effort to reduce the overall costs of their services has been described as "restructuring", "reconfiguring", "reengineering" or more commonly "merging" (Krishnan, 2001;Kjekshus & Hagen, 2007;Ahgren, 2008). Merging does not necessarily result in the closure of one hospital and the extension of another, nor does it imply that a new investment replaces two or more older hospitals. A "merger" may mean that hospital services are reduced in one hospital and concentrated in another so that the former hospital retains only a limited number of specialties or services. Whilst efficiency is obviously the predominant criterion in the merging process, the sensitive nature of health and healthcare requires that policy-makers equally value the usually contradicting (to efficiency) criterion of access equity. retrospective studies which examined the effect of a particular merger have been inconclusive as to the impact on inpatient cost (Haas-Wilson & Garmon, 2011;Tenn, 2011;Thompson, 2011). Other studies having examined the impacts of large numbers of (mostly) private hospital mergers in the US found, in general, little benefit from merger and consolidation (Ho & Hamilton, 2000;Krishnan, 2001;Spang et al., 2001;Town et al., 2006;Dafny, 2009). Case studies of hospital mergers in the UK have highlighted the fact that the pre-merger forecasts of savings in management costs were eventually over-optimistic (Fulop et al., 2002;Hutchings et al., 2003). Finally, a recent UK study examined the impact of mergers on a large set of outcomes including financial performance, productivity, waiting times and clinical quality and found little evidence that mergers achieved gains other than a reduction in activity (Gaynor et al., 2012).
The Greek literature lacks studies on merger efforts in the health sector although many parametric or non-parametric efficiency measurement studies have demonstrated the potential for efficiency gains in Greek hospitals (Aletras, 1999;Athanassopoulos et al., 1999;Athanassopoulos & Gounaris, 2001;Giokas, 2001;Kontodimopoulos et al., 2006;Aletras et al., 2007;Flokou et al., 2011;Kounetas & Papathanassopoulos, 2013;. Empirical evidence is an important factor to guide decision-making, however the existing political and economical situation in Greece, in conjunction to an intense social turmoil, implies that restructuring should rely less on technical and analytical tools, and more on various social, political, geographical and other peculiarities existing nationally and locally in Greece.

The Economic Crisis
The long-term inefficiencies and shortcomings of the Greek NHS are well known (Tountas et al., 2002;Nikolentzos & Mays, 2008;Tountas et al., 2011). Legislative initiatives to confront these inefficiencies have been mostly unsuccessful due to political particularism, fiscal constraints and administrative weaknesses (Tragakes & Polyzos, 1998). Since 2009 the Greek economy has been facing its most severe crisis in recent history and to avert a potential default, the European Commission, the International Monetary Fund and the European Central Bank (referred to as the "Troika") agreed to a rescue package with immediate bailout loans, and more funds to follow. To secure continuity of the funding, Greece has been required to adopt harsh austerity measures to control its deficit, and their implementation has been constantly monitored and evaluated by the Troika. The Government has been addressing inefficiencies by reducing the size and costs of the public sector, resulting in tax increases and cuts in many areas, including health care. A series of measures have been adopted for the NHS Hospitals such as national tendering procedures for procurement of hospital medical products and pharmaceuticals , implementation of a DRG-based payment system  and reforms in the pharmaceutical market Vandoros & Stargardt, 2013). Hospital mergers captured the public eye and became the centerpiece of health policy reform.

Restructuring Greek Public Hospitals
The formal announcement by the MoH to embark on an effort to restructure NHS hospitals was made in early 2011 when a competent committee was set up (Liaropoulos et al., 2012) to formulate proposals from a managerial prospective in order to decrease administrative costs data. These and relative proposals made by the National School of Public Health were discussed in all Regional Healthcare Authorities (RHA) with their managers and other professional bodies, and the effort concluded in a final text (suggestions from RHA Managers which led to a proposal by the Secretary-General of the Ministry that was examined by the Deputy Ministers, and decisions by the Minister of Health) on 1 July 2011. The Central Council of Regional Healthcare Authorities (including all the above) approved these proposals by the end of October 2011 and after publication of the necessary institutional decisions, these proposals should be implemented by the end of 2011.
The reorganization of the NHS Health Units was undertaken to achieve key objectives relating to: -development of a new sustainable architecture for optimal allocation of inputs, -optimal utilization of the public health care system resources, -efficient and effective operation of the NHS Health Units thus seeking both the unified planning of health services for effective and equitable coverage of citizens by integrated and quality health services, and the necessary economies of scale in rationalization of the health system.
The completion of the hospital's network reform has led to 82 hospital units out of 131. The remaining 49 have been connected with 80 hospitals as NHS Trusts, whereas 2 not-for-profit public agencies remained autonomous. Additionally five IKA hospitals (white and blue collars' social insurance fund) were transferred to five main

Scope
The previously mentioned proposals and decisions were focused mainly on restructuring the management of NHS hospitals, merging some of them and changing the intended use of others. Apart from these important and necessary changes, there is a need for reallocation of medical and laboratory units in order to solve existing problems regarding shortages or oversupply of services in different parts of the country, which generate important inequalities in the distribution of services among the seven Health Regions. For this reason, the scope of the present study was to measure and evaluate the distribution of NHS clinical and laboratory services and workforce in relation to the population in each health region, and to formulate proposals for their proper reallocation.

Data Collection
Raw data were collected within a period of six months in 2012 from 129 Greek NHS hospitals (2 hospitals never completed and returned the forms and questionnaires), by the researchers via specially constructed data collection forms and questionnaires, and were subsequently examined and complemented with data from ESY.net, a web-based facility developed by the MoH to collect updated and reliable data from NHS hospitals on a monthly basis. Preliminary analyses were limited to a detailed description of the current situation of the Greek hospital sector. However, it should be taken into account that the study described in this article was carried out on a large scale, and constitutes the second, and most complete, effort to record imaging and diagnostic laboratories, and most importantly available human resources per hospital and per Health Region. This paper exploits the aforementioned data by comparing supply and performance indicators in each Region with the average national scores. Deviations or convergences are used to formulate specific proposals for the reengineering of the public hospital sector or the "reshuffling" of the health professionals and infrastructure at a HR level. The following section provides a detailed description of the supply and performance indicators used in this study. The data were organized according to the following thematic analytical categories: A. Hospital Clinics (National Health System or University) 1) The type and kind of clinic (National Health System (Note 1) or University) 2) The sector (internal medicine, surgery, psychiatry and intersectorial) 3

Sample
All secondary and tertiary public hospitals (ESY or University public hospitals) were included in the study (N=129). The reference population for calculating the supply and performance indicators was defined according to information collected and analyzed from the Hellenic Statistical Authority and each of the seven HRs. The total population of Greece in 2011 was 10.785.860, distributed in seven HRs (Health Regions) as follows: Map 1. The 7 Health Regions of Greece

B.1 Hospital Staff/Hospital Bed
The national average of hospital doctors per hospital bed is 0.49. The worst outcomes were observed in the 3 rd , 5 th , and 6 th HRs with 0.45 and in the 4 th and 7 th regions with 0.46 doctors per hospital bed. As a result only the 1 st HR has a rather good outcome with 0.57 doctors per hospital bed. In terms of nurses, the national average is 0.62 nurses/hospital bed, with the best outcomes observed in the 5 th (0.71) HR, while the worst outcomes come from the 3 rd (0.57) and 7 th (0.58). As far as total staff per hospital bed is concerned, best results came from the 1 st (1.20), and 5 th (1.16) HRs, while the worst from the 3 rd (1.02) and 7 th (1.04) ( Table 1). Internists   As for internists/hospital bed, the national average is 0.5 with the highest outcomes observed in the 1 st (0.54), 4 th (0.52) and 7 th (0.51) HRs. The lowest outcomes were observed in the 2 nd (0.48), 3 rd (0.47), 5 th (0.47) 6 th (0.45) HRs. Internal medicine nurses have a national average of 0.52, with best results in the 5 th (0.58) and 4 th (0.56) HRs, and worst in the 2 nd (0.5), 3 rd (0.5) and 7 th (0.48) HRs. As for total staff, internal medicine clinics present best results in the 1 st (1.05), 4 th (1.08) and 5 th (1.05) HRs, and worst in the 2 nd (0.98), 3 rd (0.97) and 6 th (0.96) HRs.

b. (General) Surgery Clinics
The national average of surgeons is 0.46, with better results coming from the 2 nd (0.54) HR, and worst from the 3 rd (0.44), 6 th (0.44), and 7 th (0.44) HRs. Surgery nurses are at a national average of 0.53, with the best results in the 2 nd (0.64) and 5 th (0.61) HRs, and the worst in the 1 st (0.48), 3 rd (0.49) and 7 th (0.48) HRs. As far as total staffing of surgery clinics is concerned, best results can be found in the 2 nd (1.18) and 5 th (1.06) HRs, and worst in the 1 st (0.95), 3 rd (0.93) and 7 th (0.92) HRs.

c. Cardiology Clinics
The national average of cardiologists per bed is 0.49. The best results came from the 1 st (0.62) and the 2 nd (0.52) HRs, and the worst from the 3 rd (0.37) HR. Cardiology clinic nurses are at a national average of 0.73. Best results were observed in the 1 st (0.81) and 5 th (0.77) HRs, and worst in the 3 rd (0.67) and 7 th (0.56) HRs. As far as the total staff of cardiology clinics/bed is concerned, the best indicator results comes from the 1 st (1.43) and 2 nd (1.21) HRs and the worst from the 3 rd (1.04) and 7 th (0.99) HRs.

d. Pediatrics
The national average of pediatricians is 0.56. The highest ratio is in the 1 st (0.67), 2 nd (0.61) and 7 th (0.65) HRs, and the lowest in the 3 rd (0.47) and 6 th (0.48). Pediatric nurses per hospital bed are on average 0.46. The best results in this respect come from the 5 th (0.59), 1 st (0.54) and 3 rd (0.5) HRs, while the worst from the 4 th (0.41) and 6 th (0.43) HRs. As for total staff/bed, the best indicator is evident in the 1 st (1.21) and 5 th (1.14), while the worst in the 3 rd (0.97), 4 th (0.94), and 6 th (0.91) HRs.

e. Obstetrics -Gynecology clinics
Obstetrics/gynecology doctors per bed are at a national average of 0.41. The best ratios are observed in the1 st (0.48) and 3 rd (0.44) HRs, and the worst in the 5 th (0.35) and 6 th (0.37). The national average of nurses in obstetrics-gynecology is 0.69. Thus, HRs exceeding the national average are the 4 th (0.8) and 5 th (0.7), whereas those lagging are the 2 nd (0.62) and 6 th (0.6). As for overall staff, the best indicators are from the 4 th (1.19) and 3 rd (1.16) HRs, while the worst from the 2 nd (1.02) and 6 th (1.04) HRs.

f. Intensive Care Units
Intensive care doctors per hospital bed are 1.08. The best outcomes were observed in the 2 nd (1.22) HR, and the lowest in the 3 rd (0.85). The national average for nurses is 2.92, with the highest results found in the 4 th (3.8) and 5 th (3.62) HRs. The worst HR was the 3 rd (2.15).As for total staff, the best results came from the 4 th (4.95), 5 th (4.75), and 7 th (4.13) HRs, while the worst from the 3 th (3.0) and 6 th (3.9) HRs.

g. Orthopedics
The national average of orthopedics doctors per hospital bed is 0.43. The best results were found in the 1 st (0.58) HR, and the worst in the 4 th (0.33). Orthopedics nurses are 0.42 per hospital bed. The best outcomes can be found in the 1 st (0.52), 3 rd (0.5) and 4 th (0.44) HRs, and the worst in the 2 nd (0.3) and 7 th (0.3).When adding the number of doctors and nurses, the best indicators is in the 1 st (1.1), 3 rd (0.97) and 6 th (0.8) HRs, and the worst in the 5 th (0.2), 2 nd (0.76), and 7 th (0.65) HRs.

h. Pneumonology clinics
The average number of pneumonologists per hospital bed is 0.45. The highest ratio is in the 4 th (0.54) HR and the lowest in the 2 nd (0.37). Nursing staff have a national average of 0.47, which is exceeded by the 5 th (0.79), 3 rd (0.49) and 1 st (0.48) HRs. As far as total staff is concerned, the best results were observed in the 4 th (1.01) and 5 th (1.28) HRs, and the worst in the 2 nd (0.70) and 6 th (0.9) HRs.
i. Psychiatric clinics The national average of psychiatrists per hospital bed is 0.39. HRs exceeding this average were the 1 st (1.06), 5 th (0.75) and 3 rd (0.55). The worst HR in terms of deviation from the national average was the 2 nd (0.14). The national average of nurses/psychiatric beds is 0.76, with best outcomes found in the 1 st (1.22) www.ccsenet.org/gjhs Global Journal of Health Science Vol. 7, No. 5;2015 and 5 th (1.45) HRs, and the worst in the 2 nd and 3 rd , with 0.65 and 0.61 respectively. As for doctors and nurses combined, the best outcomes come from the 1 st (2.28) HR, and the worst from the 2 nd (0.79).

j. Ophthalmology clinics
Ophthalmologists are at a national average ratio of 0.7 and HRs exceeding this figure are the 1st (0.85) and 2 nd (1.04). Those lagging are the 5 th (0.49) and 7 th (0.54) HRs. As for nurses, their national average is 0.41. Again the best results for this indicator were found in the 1 st (0.53), and 2 nd (0.48) HRs, while the worst in the 7 th (0.28), 3 rd (0.31) and 4 th (0.33). As for doctors and nurses combined, best outcomes were observed in the 1 st (1.39) and 2 nd (1.52) HRs, while the worst in the 5 th (0.86) and 7 th (0.82) HRs.

Discussion
Starting from hospital beds per 1.000 population, even though OECD and EU-15 countries seem to do better than Greece in this ratio (4.8 and 5.3 respectively), one has to take into account that their respective indicators have been calculated with the inclusion of private hospital beds (OECD, 2013; WHO Regional Office for Europe, 2011). If private hospital beds were included in the present study, the hospital beds/1000 population indicator for Greece would increase to approximately 5 hospital beds (70% public and 30% private) per 1000 population. As a result, the indicator is further adjusted to 3.5 public hospital beds per 1000 population, including psychiatric hospital beds. Thus, HRs that surpass 3 hospital beds per 1000 population, perform rather well when compared to international standards, while the rest are required to add more hospital beds. Alternatively, a transfer of hospital beds is suggested according to two criteria, geographical proximity and the surplus of hospital beds in some HRs. According to the analysis, most HRs are above the national benchmark of 3 hospital beds/1000 population, and those lagging are the 2 nd , 5 th and 6 th (though the latter is borderline, i.e. 2.83). Thus it is proposed, based on this research, to reduce beds in the 1 st (-12%), 3 rd (-8%) and 7 th (-9%) HRs and to increase through transfers those in the 2 nd (especially in the Aegean Islands) and 5 th HRs (Table 5). Supplementary to the above, it is important to note that it is proposed that relative changes be planned within the hospitals concerning the clinics-departments. Indicatively, in the 1 st HR pneumonology clinics should be merged from 20 to 12 (and the beds respectively), while gynecology and pediatric clinics should be developed at selected large hospitals (redistributing existing beds). In the 2 nd HR, psychiatric clinics should be merged from 13 to 7 (and the beds respectively), while orthopedic, pneumonology and ophthalmology clinics should be developed at selected hospitals (and the beds respectively on the islands). In the 3 rd HR, ENT clinics should be merged from 12 to 9, while orthopedic beds should be reduced and psychiatric beds should be increased. In the 4 th HR pneumonology clinics should be increased from 5 to 10 (and the beds respectively), and cardiology -orthopedic clinics from 14 to 17 (redistributing existing beds). In the 5 th HR psychiatric clinics should be increased from 2 to 5 and ICU from 5 to 8 (and the beds respectively). In the 6 th HR gynecology and pediatric clinics should be merged from 22 to 16 and from 19 to 14 respectively, while pneumonology clinics should be increased from 6 to 9 (and the beds respectively). Finally, in the 7 th HR the proposal concerns a reduction of pneumonology and pediatric beds.
Concerning human resources ratios, the HRs exceeding 1.3 NHS doctors per 1.000 population score rather well, while the rest need to hire more doctors or transfer doctors from a nearby HR, that exceed 1.3 doctors per 1000 population, such as the 1 st , the 3 rd , the 4 th and the 6 th HRs. On the same line of analysis, HRs that need urgent staff support are the 2 nd , and mostly the 5 th HRs (Table 5). The issue of 2 nd RHA is complicated because of many islands and needs further consideration concerning HR transfers. 5 th RHA must be supported mainly from 3 rd and 4 th . The HRs that exceed the ratio of 1.7 nursing staff per 1.000 population are performing rather well, while regions below this threshold need to be supported with additional nursing staff. Alternatively to hiring around 3000 nursing staff, it is suggested to reshuffle nurses between the regions that are close enough and exceed or lag from the national average. According to the analysis of the raw data collected from the public hospitals all over the country, the 1 st , 4 th , 7 th , and marginally the 3 rd (1.75) and the 6 th (1.71) fulfill the threshold of 1.7 nurses per 1000 population. The ones that fail to reach the threshold, the 2 nd and the 5 th , need support from either the 1 st or the 3 rd and the 4 th HR respectively. The situation in regard to other (non-medical and non-nursing hospital staff) is almost similar (Table 5).
Specific reference should be made for the reengineering of ESY hospital laboratories. Mergers are needed in the 1 st , 6 th and 7 th HR, especially in biochemistry (1 st and 7 th ) and microbiology, as well as in medical imaging labs (6 th ). The remaining HR need selected improvements, e.g. the 2 nd HR (blood banks and pathologoanatomy labs), the 4 th HR (cytology labs) and a few biochemistry labs in the 3 rd and 5 th HR (Table 6).  Finally tables 7 and 8 present the reengineering and reshuffling of hospital doctors and nurses of the hospital clinics-departments of the main specialties. Transfers of doctors are proposed from the 1 st HR (Athens) to the 2 nd HR (mainly islands), orthopedic doctors from the 3 rd to the 4 th HR and internal medicine doctors from the 4 th to the 3 rd HR (both mainly within Salonika), general surgery doctors from the 3 rd and 4 th to the 5 th HR, which needs doctors in other specialties as well (transferred from other HRs). On the other hand, nurses' shortage is obvious all over the country. Because of the current restrictions to hire new personnel, as a result of the economic crisis, our suggestion is a selected transfer of nurses between neighboring HRs like 1 st to 2 nd , 4 th to 3 rd and 6 th to 5 th .