The psychiatric staff goes on mass protests
Last Tuesday, despite quarantine restrictions, 150 employees of Kyiv Psychiatric Hospital went to a mass protest. Within the framework of the medical reform second stage, which started on April 1, the government allocates to the institution only 22% of the financing it needs - the deficit of funds is 155 million UAH (5,5 million USD). "The state allocated for us and other psychiatric hospitals in Ukraine only one-third of the necessary funding. To meet this money, I need to fire about 35-40% of the workers," the head physician of the hospital, Vyacheslav Mishiev, told the media. 450 employees or 11 people from each department (the entire staff is 1,401 people) can be fired from the hospital, and those who remain will receive minimal wage within the existing funding.
In a similar situation is the Lviv Regional Clinical Psychiatric Hospital. On April 3, the hospital, which is the largest psychiatric care center in the western region, reported on a Facebook page that as a result of a catastrophic decrease in funding (only 20% of the need for 9 months from April to May), it was on the verge of financial and social collapse. The hospital does not have enough funds for food and maintenance of patients. According to the general director of the medical institution, Bogdan Chechotka, the funds stipulated by the contract with the state are not enough for salaries, food and medicines for patients. Without funding appears an outpatient service for thousands of patients with schizophrenia and epilepsy - disabled people who are legally entitled to free treatment. It should be noted that in Ukraine as a whole, according to the Association of Psychiatrists, only 10 out of 53 medical institutions with a psychiatric profile after April 1 received funding for preferential medical care for patients on an outpatient basis.
Employees of Lviv psychiatric hospitals joined the protest of their Kyiv colleagues.
The Regional Clinical Hospital in Slovyansk for 9 months of 2020 (from April 1 to December 31) under the contract with the state is financed by 18.4%, the psychiatric hospital in Mariupol - by 38%, the psychiatric hospital in Kramatorsk - by 37%. Vinnitsa Regional Psychiatric Hospital No. 2 was funded by 22.4%.
In total, according to the Ministry of Health, 58 specialized psychiatric hospitals have concluded agreements with the state, the funding of which was reduced by an average of 2 times. The total underfunding of psychiatric hospitals in Ukraine is 898 million UAH (over 32 million USD), according to the Ministry of Health.
Psychiatrist, psychotherapist, medical director of the Regional Specialized Hospital in Glukhiv (serves 6 districts of the Sumy region, accepts patients from Sumy, treated 1,500 patients in 2019) Evgen Skrypnyk said that despite a relatively better situation than the others (the the institution from April to December is funded to 71% of the need), the case is complicated.
“Of the money that the state gives us, we must pay pensions to our former employees who went on a preferential pension, which is about 30 thousand UAH (1070 USD) per month. We have four people serving in the army, and we also have to pay them wages from the same funds," Skrypnyk said. According to him, in the current situation there is a shortage of funds for the payment of salaries to medical staff. The institution is faced with the need to reduce beds (even before the second stage of the reform they were reduced by 10 to 160). If funding is not increased, at least 30% of employees will have to be fired. Skrypnyk warned that without adequate funding, the diet of patients, the level of provision of medicines, could deteriorate.
State urges hospitals to earn money
The second stage of the medical reform implies that part of the financing of medical institutions should be executed by the expense of patients: they say that hospitals should provide guaranteed services for which the state pays, but they must also organize paid services. Such a model cannot be implemented in Ukrainian psychiatry, said Simon Gluzman, president of the Association of Psychiatrists: “In no normal country can a psychiatric service earn money due to its specifics. In Canada there are only two private psychiatric hospitals, and there are also a few of them in the States. All this is very expensive".
Yevgen Skrypnyk agrees with him: “Our institution does not provide such services for which payment may be made. We have nothing to hope for financing from the services provided for co-payment. We were told that we should look for opportunities to provide such services that we could sell, but the sphere in which we work does not provide such opportunities".
Of the 27 packages of guaranteed medical services in the field of psychiatry, the state pays for only two: "Psychiatric care for adults and children", as well as "Treatment of people with mental and behavioral disorders due to the use of opioids using substitution therapy drugs." Thus, without going into details, the state calculates the budget of mental hospitals, based on the base of 7.2 thousand UAH (258 USD) for the treated case. “This amount includes all services (food, medical treatment, salaries for doctors), all services, except utilities. This amount is paid regardless of the severity of the case and the length of stay of the patient in the institution, which is 10 days, which is 2-3 months (and some cases, indeed, they require such a long treatment)," said Yevgen Skrypnyk.
Doctors believe that funding should be increased at least twice - up to 14 000 UAH (523 USD) for the treated case and take into account the specifics of the cases: the effect of some drugs that are used to treat mental illness occurs 2-3 weeks after the start of their reception, and some cases require a longer, up to several months, treatment.
In a letter sent to the Ministry of Health (in connection with problems arising from the second stage of medical reform), the director of the Slovyansk psychiatric clinic, Yuri Smal, notes that "psychiatric care is different from medical care in other areas. It implies a longer stay of patients, the need to address the social issues of patients who have lost family ties, including compulsory medical measures. "
Forced to throw patients to the street
In the current situation, the greatest threat hangs over the chronically ill, who, by virtue of circumstances, live out their lives in mental hospitals. As a rule, such people have nowhere to go, and now the staff of mental hospitals will be forced to either keep them at their own expense, or throw them out into the street, which is now happening.
The problem of "social beds", as they are called in the medical environment, in psychiatry is more than large-scale. “When we interviewed the head doctors of psychiatric hospitals on how many people for medical reasons should not be in a medical institution, it turned out that this figure was about 30% on average. Of course, sometimes this happened because the reduction in the number of patients is not profitable, which would have led to a reduction in the conditions of financing according to the old principles (based on the approaches of a planned economy), but most often the main reason was different - the doctors simply had nowhere to put these unfortunate people. They were not so sick as to keep them in the walls of a mental hospital, but they had nowhere to go: some of these people lost their homes, their families collapsed. Some of these patients were simply refused by relatives, considering them a burden. We call this the problem of "social beds," Simon Gluzman said.
As an expert psychiatrist, I took part in monitoring visits organized by the Human Rights Commissioner Secretariat. In particular, we visited neuropsychiatric hospitals, in which we were faced with the fact that in such institutions there are a lot of people who cannot be discharged because of their mental state or because they have lost social and family ties. Skrypnyk said: “Such people live in hospitals sometimes for 10-20 years. There are few such people in our medical institution, but they exist. Now we and other medical institutions will be forced to discharge such patients!”
Another reason that will push doctors to discharge patients of "social beds" is that the state pays money only for treated cases, upon discharge. After all, the principle is that money goes after the patient.
The problem is acute due to the lack of a rehabilitation system for people with mental illness in Ukraine. In parallel with the reduction of beds in psychiatric hospitals and the closure of institutions, which took place throughout the years after independence, the role of dispensaries that provided outpatient treatment and rehabilitation institutions should have been strengthened. This did not happen, says Gluzman. Most dispensaries, which were still afloat, could offer only medicines of outdated generations. Some of them caused serious side effects or did not have the proper effect.
“The worst thing is that Ukraine did not pay attention to the formation of an intermediate link that is widely developed in civilized countries: nursing homes, dormitories, halfway houses, which would receive patients who have been treated, rehabilitated, and regain life skills in society. This practice much cheaper than an expensive hospital system, "said the president of the Association of Psychiatrists of Ukraine in a comment to 112.ua.
In Ukrainian realities, the head doctors of mental hospitals may try to transfer socially unprotected patients to boarding schools subordinate to the Ministry of Social Policy. And although the living conditions in them are far from perfect, which was repeatedly confirmed in the course of journalistic investigations, taking a person in such an institution was and remains a difficult task.
Executive Director of the Foundation for Human Rights in the Field of Psychiatry, Dutch human rights activist Robert van Voren told the 112.ua correspondent the story of a girl (in 2018 she was 20 years old), who at the age of 9 was placed in a boarding school by her own aunt who occupied a three-room apartment of the girl’s parents in Slavyansk. Despite the fact that the girl had the only developmental disability (abnormally short stature), she was given a psychiatric diagnosis and declared legally incapable, which in Ukraine is a lifelong status. Guardianship was issued by an aunt who, in addition to the apartment, also received a disability pension. Moreover, over the 11 years during which her niece could not go beyond the walls of the boarding school, her aunt never visited her. Robert maintained communication with the girl and helped her through the court to achieve the abolition of the status of incapacity (in a third-party suit). There are no procedures in which a person can challenge the grounds for his stay in a boarding school in Ukraine. Such cases are not unique.
At a press conference in Ukrinform (based on the results of neuropsychiatric boarding schools inspection) with the participation of Robert van Voren and Simon Gluzman, it was reported that mass human rights violations were committed in Ukrainian psycho-neurological boarding schools: patients were not asked for consent to treatment, they were subjected to forced isolation. In boarding schools, people are often in conditions of "life imprisonment", including those who got there through malicious intent or as a result of a diagnostic error. There are cases when directors of boarding schools take custody of those patients who did not have any relatives, receiving their pension for them. Robert van Voren talked about a case when a director of a boarding school received 200 persons, receiving a total of up to 2 000 euros per year instead of patients.
On January 1, 2020, the new Law "On Social Services" entered into force, which was supposed to make revolutionary changes, including in the field of rehabilitation of people with neuropsychiatric diagnoses, but in reality the document was not able to operate due to the lack of necessary by-laws. Most of them are still not approved.
In this regard, it is almost impossible to get into a boarding school today. “The Law on Social Services canceled all the by-laws of the Ministry of Social Policy, including the provision on boarding schools, and the procedure for applying to these institutions. The new regulatory framework has not yet been developed. Despite the fact that there are enough vacant seats, from January, not a single new person could get to boarding schools, including people with mental illness," confirmed Yevgen Skrypnyk. He noted that relatives of patients have often addressed this problem recently. They are seriously worried.
Consequences will be disastrous
If the authorities do nothing and the situation does not change for the better, the consequences will not be long in coming. The quality of psychiatric care in Ukraine will decline to a critical level, which is especially alarming in the context of the coronavirus pandemic, which, according to scientists, can lead to an increase in cases of mental disorders, as well as taking into account the presence of problems in people who have gone through Donbas conflict.
There will be no one to help. At the current level of funding, according to the Association of Psychiatrists of Ukraine, 53 psychiatric hospitals will be forced to reduce 3,164 workers, including doctors and nurses. The rest, most likely, will quit, taking into account the increased workload and small salaries.
Patients of "social beds" will be thrown out into the street, where, most likely, they will be doomed to death. About this, by the way, back in February told the director of the First Regional Specialized Hospital of Romny Volodymyr Kulbachny. On behalf of a group of psychiatrists, he registered a petition on the president’s website.
"Citizens of Ukraine suffering from mental disorders are in many cases poor people who are unable to meet their minimum necessities of life, who have no money and in most cases are at home. They are not needed by society and relatives, some of them have been in institutions of psychiatric care for many years and needs constant care, supervision and medical treatment. The reform of secondary and tertiary care, planned for April 2020, does not provide funds for the treatment of this category of patients, so they will be forced to leave the hospitals that were previously their home and go into a society, into a life to which they are not adapted. Most of these patients will die within 3-6 months, some will violate the law and will end up with compulsory medical measures of various levels," the doctor warned.
Gluzman also speaks about the serious consequences of this approach: “Not all mentally ill people are dangerous to others, most often they are dangerous to themselves. But when they receive at least some not even the most advanced treatment, they also receive not the most modern drugs, they have the state of arousal decreases, the hallucinatory syndrome goes away, the delirium becomes softer. And when we simply throw away such a patient, there is a risk that the symptoms will aggravate. And suddenly the hallucinatory voice will say to him: "This stranger is the culprit of your troubles, go strangle him."
And what do the Ministry of Health think about this?
The Ministry of Health recognizes the problems in the field of psychiatry generated by the second stage of medical reform. The day after the protests of employees of the Kyiv and Lviv mental hospitals, Minister of Health Maxim Stepanov said at a briefing that there was a problem: he stated that the hospital received only 50% of the funding it needed. "They were on the verge of closure precisely because the tariffs that were calculated - they do not correspond to reality ... Speaking in the language of numbers, the total underfunding is 898 million for all psychiatric hospitals. This figure put many psychiatric hospitals on the verge of closure," said Stepanov.
He assured that the Ministry of Health will soon develop a mechanism that will allow reforming the psychiatric service: “We will make a substantial revision of the reform, we want the hospitals not to be closed after the reform. As for the psychiatric hospitals, according to the calculations that we are completing, the psychiatric service will be funded separately "a mechanism that allows it to be reformed according to a clear criterion, and, on the other hand, so that we do not lose it."
Easy to say, but hard to do. It is unclear where to get funds now to patch up holes and finance psychiatric hospitals at least for the 2019 subvention level. In addition, most issues require legislative settlement. "What is Stepanov’s tragedy? He understands everything, but can’t change anything, because you need to change the legislation - a whole array of bills that have been adopted in recent years and entered into force," concluded Gluzman.