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Chapter I

Introduction

1.1 The Foundations and Importance of this Research

It is widely accepted that innovation has assumed great importance for organisations

in sustaining their competitiveness (e.g. Tidd et al , 2005; Bernstein & Singh, 2006;

Ussman et al , 2001; De Propris, 2002). Blumentritt et al (2005), whose study

concentrates on how entrepreneurs develop internal cultures that may inspire and impel

innovation, argue that continuous innovation requires organisational systems and

procedures that are embedded, so as to ensure growth. From an entrepreneurial point of

view, Simmons et al (2009) state that entrepreneurship creates value through

innovation, seizing business opportunities. Similarly, Johnson (2001), who conducted

research on entrepreneurship and innovation, contends that entrepreneurship is the

conversion of ideas into marketable products or services.

Little research has been conducted about new service development in the health

service industry, with only a select number of notable works available: Duncan and

Breslin, 2009; Windrum and Garcia-Goni, 2008; Booz et al , 1982. Elsewhere,

Nambisan’s study (2002, p. 394) argues that in many different markets and situations,

customers are an excellent source of innovation (a view supported by Veryzer & de

Mozata, 2005). Tobin et al (2002, p. 93) also stress the importance of communication

and building a relationship with patients, stating: “the opportunities for consumer

participation occur first at this clinical interface in terms of what information is

transferred, in what direction, and in how the communication takes place. Nurturing

participation at this level has a fundamental role in consumer empowerment”.

Despite the importance of both entrepreneurship and customer-orientation in the

health care market, little has been written on either subject. The present study focuses

on the health services industry, examining both the demand for and provision of mental

health care in Greece. Within the structure of the health system in Greece, the private

health services sector includes Diagnostic Centres and Hospitals (general and obstetric

clinics), which are classed respectively in Primary and Secondary Health Care.

However, in recent years the industry has experienced great change following mergers

of organisations operating in the three wider sectors (general clinics, obstetrical &


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gynaecological clinics, and diagnostic centres). This has resulted in the growth of health

care groups offering a full range of diagnostic and treatment services. As the market for

private health care has grown, so too has the competition between organisations, each

trying to offer better service quality, promptness, and facilities than one another.

As regards the mental health care sector, it becomes apparent that there is a

noteworthy improvement in the areas of decentralisation of mental health services

(Madianos et al , 1999b). Yet there is much still to be done in terms of quality and

delivery of mental health care services. What is more, the mental health service sector

is not very highly exploited. There are few private independent hospitals of this kind

across Greece, even though the public sector appears not to satisfy the needs of the

patients. Detailed information can be found in Chapter 2.2.4.

The organisation that is the focus of this study is a leading player in the area of

diagnosis, prevention, and hospital care in Greece. Euromedica Group is mainly

involved in the foundation, organisation, and operation of clinical and scientific centres,

equipped with high-technology appliances. The organisation’s facilities serve ten

prefectures in Greece, while it invests in its personnel through continuous and extensive

training of its employees. In 2008, Euromedica recognised an unfilled niche in the

market for health care, that of mental health services. Following extensive market

research into this area of the health care market, including the limited availability of

such treatments geographically, the organisation decided to invest in and develop their

own services in this area. Therefore, this research provides important managerial

implications for the top management team of the Euromedica Group, regarding its

overall operation and particularly its mental health care division. Specifically, the

results of this research work give a factual picture of mental health services provision

within the organisation, along with the techniques that should be adopted to develop

and implement customised or personalised offerings for customers. Such action should

offer substantial competitive advantages to the Euromedica Group as well as the

opportunity to expand its operations within the mental health sector.

1.2 Current State of Knowledge and Research Questions

The researcher reviewed the research context and theoretical background in order

to identify the knowledge gaps and critical problems in the Greek health care industry

and especially in the private sector. After reviewing these resources, the research


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questions relating to these knowledge gaps and aiming to solve critical problems were

composed.

1.2.1 Overview of the Research Context

In private sector health services, providers operate large-size companies, well-organised and with extensive experience in the health sector, which in many cases

constitute powerful business groups. Moreover, in most cases, physicians, apart from

their role in providing medical care, participate actively in management as shareholders

in these companies.

The failure of the public sector, in conjunction with structural problems of the Greek

NHS, identifiable primarily as inadequate infrastructure, technological retardation, and

lack of medical-nursing personnel, is a very strong point for the industry in question.

The rise of living standards, the gradual ageing of the population, the emergence of new

diseases, and the increasing number of people covered by private insurance companies,

all contribute to the gradual increase in demand for private health services and

preventative medicine. Moreover, the evolution of medical science in conjunction with

the development of technology in the health sector, create growing demand for direct,

more efficient and higher quality health services.

Especially in recent years, large firms, as members of international organisations,

maintain partnerships with major medical institutions abroad, thus ensuring their

participation in various research projects. Finally, a strong point for the industry is

considered the ‘industrial peace’ in the private sector, as opposed to the public, where

the strikes of the medical-nursing staff are very common.

Competition is particularly fierce in the sector of private health services. The entry

of a new business into the industry of private health services, from the technical and

economical points of view, is therefore not an easy task. The obstacles to the creation

of new companies in the industry are placed by the current institutional framework. In

the case of hospitals, conditions and especially the construction specifications are

considered by stakeholders as particularly severe. At the same time, health services are

targeted to individual consumers, hence their, health service providers', bargaining

power is limited. However, the opinion of the doctor of a patient, always in combination

with that of the insurance company (if one exists) and of course, a good knowledge and

awareness of the market, may lead them to choose the most economically advantageous

solution in the context of their own needs and requirements. Finally, foreign markets,


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particularly the countries of Eastern Europe and Turkey, which show significant

deficiencies in health infrastructure, have concentrated, especially in recent years, the

interest of investors of large business groups. The geographic imbalance of private

nursing units also creates growth opportunities beyond Athens and Thessaloniki, where

the largest number of them is currently concentrated. This is reinforced by the fact that

there is considerable room for improvement in the quality of health care in regions

outside of Athens and Thessaloniki. The extension of cooperation of private health

facilities with an increasing number of private insurance companies, as well as the

contracts with insurance funds, has resulted in broadening their customer base through

the coverage of medical expenses for a greater range of patients.

Moreover, the increasing number of migrants, whose economic profile does not

enable them to benefit from private health services, has led to congestion of public

hospitals, an element that turns a part of demand towards the private sector. In addition,

the proliferation of programmes through interest-free instalment payment is a reality

now in the field of private health, as is the “outpatient card”, which offers scalable

discounts for series of medical tests. Lastly, home care, provision of day nursing

services, tele-medicine, and robotic surgery, rehabilitation centres, nursing hostels and

geriatric clinics and stem cell banks are all areas that have significant growth potential

in Greece, while paediatric, gynaecological and oncology units, plastic surgery centres,

IVF centres, and even centres of natural health and wellness, concentrate the interest of

investors.

1.2.1.1 The Greek Health Care Market

Especially in recent years, the industry is characterised by significant changes due

to mergers and acquisitions between companies in three broad areas of activity (general

clinics, obstetric and gynaecological clinics, diagnostic centres). One result of this trend

is the prevalence of multi-purpose business groups for medical services, which offer a

full range of services for diagnosis and treatment. The competition between private

health units, has been particularly intense in recent years and focuses primarily on the

replacement of medical equipment; the range, quality enhancement and the speed of the

services provided; the extension of the network (presence in most areas); and

cooperation with insurance funds.

Furthermore, the total domestic market for private health services (in value) shows

longitudinal growth during the period of 1998-2008; its size was estimated in 2008 at

€1.985 million, compared to €574 million in 1998, representing average annual growth


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rate 13.2%. In the area of private hospitals, the greatest market shares appear to be held,

for 2008, by Hygeia Group and IASO Group, followed by BIOMED and Euromedica.

1.2.1.2 Euromedica Group

Euromedica Group has 44 diagnostic centres covering all medical specialities; 18

general, obstetrics and gynaecology hospitals; 9 rehabilitation and recovery centres, as

well as one spa, health and cosmetic surgery centre, having a total capacity of 1621

beds. The Group's principal activities are the provision of health and wellness solutions,

all over Greece.

Euromedica Neurological Services is the leading provider of private mental health

treatment and associated care services in Greece, with a network of 3 acute hospitals

and care homes (Thermaikos, Castalia and Galini), which employ more than 350

people. The organisation offers a range of inpatient, outpatient, day patient and

residential treatment programmes, as well as therapy services that include condition

management programmes as well as psychological and psychiatric services, such as

secure and step-down services, complex care and rehabilitation services. It also

provides autism services and care of the elderly. It continues to establish new services

each year in partnership with government bodies.

1.2.2 Theoretical Background

The framework (Fig. 1.1) provides an overview of the main groups of literature

that formed the basis for this study. Four theoretical concepts were adopted and studied:

Theory of Service Innovation; Theory of Corporate Venturing; Theory of New

Service/Product Development; Theory of Customer Orientation. Each one is discussed

in detail and in relation to one another in the following sections of this research thesis.

Figure 1.1 Theoretical Framework of the Research


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1.2.2.1 Corporate Venturing and Innovation

Many authors have highlighted the lack of research regarding the synergy between

innovation and entrepreneurship (e.g. Zhao, 2005a; McFadzean et al, 2005). In

particular, Zhao (2005a, p. 25) states, “the combination of entrepreneurship and

innovation holds the key to organisational sustainability.” He also argues (Zhao, 2005b)

that the synergy between the two concepts helps the organisation prosper and in

addition, reports (2005a, p. 28) that “innovation is the specific tool of entrepreneurship

by which entrepreneurs exploit change as an opportunity for a different business or

service”.

Another group of authors link innovation and entrepreneurship and draw similar

conclusions and postulations to Zhao (2005a) are McFadzean et al. (2005), who

produced models displaying their holistic definition of entrepreneurship and

innovation, and another displaying the attitudes, visions and actions necessitated,

according to the authors, to act as the linkages between innovation and corporate

entrepreneurship.

The responsibilities of the corporate entrepreneur are, according to various authors

(e.g. Barringer & Bluedorn, 1999; McFadzean et al, 2005; Thornberry, 2001; Guth &

Ginsberg, 1990), intrinsically linked to the task of innovation, and include tasks such

as locating and assessing new opportunities, managing resources and perhaps

challenging bureaucracy. Kelley (2011), who carried out research aiming to describe

how traditional companies can apply corporate entrepreneurship to their operations,

also links and draws parallels between, not only corporate entrepreneurship and

innovation, but also innovation and the ability to enhance an organisation’s competitive

positioning and to provide outstanding value for its customers. Another study

conducted by Zhao (2005a) suggests that innovation and entrepreneurship are dynamic

and holistic processes that are not restricted to the initial activity of a new undertaking.

This can be viewed in the light of De Burcharth and Ulhøi’s (2011) recent study; they

examine alternative organisational approaches to producing radical innovation and

report that such innovation usually derives from new business ventures.

However, Zhao (2005a) warns of the potential dangers of being a highly innovative

organisation, such as the lack of real measurability of the contributions of

entrepreneurship and/or innovation, or conversely, such successful innovation leading

to potential job losses (through improved technologies). Issues may also arise with


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regard to managers potentially feeling that they are losing their control over an

organisation or department when they allow for increased creativity and freedom for

staff.

Some authors support the opinion that corporate venturing is a viable option only

for large organisations who are able to supply the expenditure realistically required to

succeed in this task (Gapp & Fisher, 2007; Zahra, 1996). However, corporate venturing

can prove an effective option for firms to gain knowledge and skills that will often lead

to future revenue streams (Greene et al, 1999). According to Tidd and Barnes (2000, p.

109), however, “many firms (in life sciences industries) have failed to differentiate

sufficiently between strategic, financial and operational goals, and have therefore

created inappropriate forms of corporate venture.” Therefore, one of the key objectives

of this research is to investigate the relationship between innovation and corporate

venturing within the health care industry.

1.2.2.2 New Service Development and Customer Orientation

Continuous service innovation has been described by many authors (e.g. Smith et

al, 2007; Tidd & Hull, 2003; Day & Wensley, 1988; Storey & Easingwood, 1999) as

the most valuable means for companies to achieve long-term success and organic

growth (Melton & Hartline, 2010). It is also suggested that for service firms to achieve

even greater success, a customer-orientation perspective should be adopted (Sing Wong

& Tong, 2012; Svendsen et al, 2011; Ottenbacher & Harrington, 2008). This position is

enhanced by Greer and Lei’s (2012, p. 63) recent study, which emphasises how

enterprises undertake collaborative innovation with individuals and business customers

and concludes, “Collaborative innovation with customers or users is increasingly

important for the development of new products and services.”

Rehme and Svensson (2011), combine entrepreneurship and marketing theories to

illustrate the approaches that new ventures employ to achieve key milestones. They (p.

6) clearly support the above viewpoint mentioning that “firms that involve customers

or users in their product development processes are more likely to succeed in the market

than firms that do not at an early stage receive feedback from users, and direct customer

involvement in the development of their offering is likely to increase revenues with a

guaranteed sale, making it necessary for them to have a strategic view on customer

involvement”. Similarly, Jenssen and Aasheim (2010) carried out research that analyses

the effects of organisational factors on innovation and performance in knowledge-

intensive businesses and argue that the success of product development depends on the


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level of market contribution to the development process. Carbonell et al (2011)

reinforce this viewpoint, arguing that close customer participation increases service

advantage and speed to market, while lead-user contribution augments the novelty of

new offerings and service advantage even though this affects market performance

negatively.

When it comes to service development, Kandampully (2002, p. 19) states,

“innovation can be translated as a firm’s foresight to think for the customer by creating

services that drive the marketplace.” In a study looking at customers’ value in service

development, Jiménez-Zarco et al (2011, p. 57) state that “the value that consumers

provide derives from their use of services in day-to-day life, which makes their

experience and knowledge pertinent, particularly for increasing market acceptance of

new services, improving services, identifying market trends early and providing a

source of new ideas”.

However, consumer involvement is not without its challenges. Many authors share

the opinion that customers have a limited ability to provide valuable input into the

development process (e.g. Bonner & Walker, 2004; Christensen & Bower, 1996;

Edvardsson & Olsson, 1996). For instance, Hillebrand et al (2011) conducted a study

that aims to explore the differential effect of customer orientation and future market

focus on organisation inertia and firm innovativeness and conclude that firms become

passive and worn-out when they focus only on customers’ expectations. Likewise,

Edvardsson and Olsson (1996) note that firms should take into account the customers’

needs and wishes via an open dialogue, but they should not involve them directly in the

service development process. Taking this further, other researchers argue that the design

and the development of a new product should be carried out only by professionals

(Gales & Mansour-Cole, 1995; McQuarrie & McIntyre, 1986). Contrary to this view,

Magnusson (2003) argues that users provide more valuable and original ideas than do

professionals. However, despite such debate, customer involvement remains an

underdeveloped research area in the new service development process (Alam, 2002;

Alam & Perry, 2002; Johne & Storey, 1998), and, as discussed by Martin and Horne

(1995), direct customer participation is in any case of rare occurrence.

1.2.3 Knowledge Gaps and Research Questions

A number of studies concerning the service sectors and in particular service

innovation have been carried out, but they have rarely been conducted in the context of


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health care and in particularly, in mental health care. In addition, few studies have

focused on the interaction and involvement of patients in the development of new health

services and even less in the design and development of new mental health services.

Lastly, there is no study that aims to investigate the growth and sustainability of a health

care organisation from two different perspectives, that of service innovation and how

can this lead to the exploitation of entrepreneurial opportunities, and, on the other hand,

the involvement of customers, aiming at the development of new services that could be

used as the tool for the above growth, leading the organisation to sustainable

development. The researcher reviewed the research context of the Greek health care as

well as the relevant literature in order to develop the research questions below.

The health care industry is one characterised by innovation (Bowers, 1987), with

hospitals often acting as leaders in innovation as new treatments and technologies in

this arena emerge daily. However, this rapid rate of change can often stifle organisations

who may not have the resources to keep up and will end up suffering from business

inertia (Rohrbeck & Gemünden, 2011). Other potential problems regarding innovation

in the health care can lie in the bureaucracy and other such problems often associated

with the industry (Duncan & Breslin, 2009; Bellou, 2010). Efforts to ameliorate

problems and issues such as these have been illustrated in research by various authors

(e.g. Nijssen et al , 2006; Menor & Roth, 2007; Cooper, 1988) who suggest a rigid,

systematic approach to new service development as being able to provide a more

effective approach to successful innovation. Additionally, several studies have pointed

out the importance and contribution of customers and of the market in general in

successful service innovation, underlining that the degree of novelty depends on

customer-producer interaction as well as on the creation of a new value system among

the business partners (market orientation) (e.g. Den Hertog et al, 2010; Agarwal &

Selen, 2009). In this context, the following research question aims to examine the role

of the customers in the organisation’s innovation strategy. This will allow the researcher

to see whether Euromedica is extrovert or introvert, and also to gain a deeper

understanding regarding how the Group values customer participation:

RQ1: What is the role of customer (and of the market) in the development of

health services in Euromedica Group?


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Likewise, corporate entrepreneurship may be defined as an organisational

capability, which promotes entrepreneurial behaviour within organisations in order to

overcome internal barriers, challenge bureaucracy, and encourage innovation through

novel business schemes (Salvato et al , 2009; Echols & Neck, 1998; McFadzean et al ,

2005). It is a concept that is often associated with competitive success and is said to be

achieved through various methods. Similarly, Kraus and Rigtering (2010), who see

corporate entrepreneurship as a company philosophy, cite that corporate

entrepreneurship is a strategy that improves firms' innovative capability and raises

employee satisfaction. One component of corporate entrepreneurship in particular,

corporate venturing is characterised by the literature as a core concept in the strategic

planning of organisations to develop innovations and gain competitive advantages and,

therefore, achieve organisational sustainability and long-term growth (e.g. Korsgaard

& Anderson, 2011; Narayanan et al, 2008; Husted & Vintergaard, 2004). Similarly,

other studies have argued that corporate venturing acts as a tool to boost company’s

innovativeness, and employees appear to be a critical factor of both innovation and

business expansion (Antoncic & Hisrich, 2003; Lumpkin & Dess, 1996; Covin &

Slevin, 1991). Following those arguments, it adds up to the interest of the researcher to

explore the research question below in the mental health care context, where no similar

studies have examined the corporate venturing activity in the sector:

RQ2: How does Euromedica Group exploit innovation in services so as to engage

in corporate venturing?

Furthermore, new service development activities are of vital importance, as they

strengthen current business and create the potential for new business ventures

(Frambach et al , 2003; Igel & Islam, 2001). The necessity to develop new services is

of particular importance in the health care industry due to the nature of the services

provided. Smith et al (2007), who implemented five different models on the design and

development of new health care services, found that in order for a development process

for health services to be successful the service design should harmonise with the

organisation’s objectives and strategies and with the interests and expectations of the

key stakeholders (government, health board, etc.). Moreover, service design should

focus on users’ needs and involve both customers and a range of other stakeholders,such as front-line staff, managers, and so on, in the development process. This is


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consistent with Bowers (1987), who found that both external and internal inputs are

needed for the development of new service concepts, which then should be evaluated

by both therapists and doctors and patients. Likewise, Windrum and Garcia-Goni

(2008) developed a framework for new health service development that involves, on

one hand policy makers, and service providers and on the other, firms and consumers.

They highlighted the competences of health professionals, and their interactions with

patients, mentioning that those determine service characteristics. Nevertheless, it

became clear in the review of the literature, and as it is shown in the subsections 4.2.2.3

and 4.2.2.4, in the past years, health care organisations used to focus more on the

expectations of their medical staff and third-party payers and less on their medical

consumers’ needs (e.g. Ford & Fottler, 2000). In addition, Charles et al (1997) indicate

clinicians as the ‘perfect agents’ for their patients, and other studies have shown that

there are still doctors and nurses who believe that mental health service users have not

much to contribute to decision-making and to new service development (e.g. Bennetts

et al, 2011). The above arguments lead to the question whether medical staff agrees

with the involvement of patients in such processes and what role would they play if the

management of a hospital decides to take action by asking customers (patients and

relatives) to contribute to its innovation activities. The following research question aims

to explore medical staff’s perceptions of customer orientation, as there is no clear

picture in the literature about their role in the development of patient-oriented services:

RQ3: What are medical staff’s perceptions of customer orientation and what role

do such perceptions play in the development of patient-oriented services?

It is also widely recognised that customer-oriented businesses improve customer

satisfaction and deliver better service quality (e.g. Kelley et al , 1990; Hartline et al ,

2000). This point is particularly relevant to the health care industry as health services

need to be modified for individual patients, balancing their medical needs so as to

increase efficiency (Berry & Mirabito, 2010). Furthermore, increased customer

orientation seems positively to influence medical scientists' working practices and their

sense of professional expertise (Cohen et al , 2004). Another important point is the

increased access to information regarding health care now available to customers. This

has led the current health care experience to move from simple procedures and services,

towards a holistic process that starts before admission and is completed after discharge


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(Ford & Fottler, 2000). All this implies that executives must always consider effective

ways to provide health care services. Wood et al ’s (2000) study, suggests that health

care organisations should focus on new approaches, such as customer orientation, to

achieve patient satisfaction. Similarly, Lord (1989) concluded that the aims of involving

patients are generally to advance health outcomes, raise satisfaction, and/or reduce cost.

In recent years, users of psychiatric services have taken a more active role in their

treatment and hospitalisation. Research by Barnes and Wistow (1994) and Campbell

(2001) found that until the early 1980s, patients used to be passive recipients of their

treatment, having no participation in and little influence over the services they used.

Indeed, the World Health Organization (1990) advised that patients should be involved

in the decision-making process with regard to their treatment, yet it has been reported

in the literature that mental health patients have not been treated with equal

consideration as other types of patients (Lammers & Happell, 2003). Nevertheless,

many changes have occurred since the 1980s that have led to mental health patients

gaining increased influence over the services they receive, including users having

increased control of their care and the decisions involved, and better availability of

knowledge of the types of treatments delivered. This shows that patients are a critical

actor in service development, especially in mental health care environments. Therefore,

as many studies have noted, there is a gap in the literature regarding how mental patients

should participate in new service development (e.g. Ford & Fottler, 2000; Davies et al,

2009; Bennetts et al, 2011). The last research question below aims to address this gap:

RQ4: How should mental health service users be involved in the service

development process?

1.3 Overview of the Limitations of the Literature

As already mentioned, little research has been conducted studying the relationship

between innovation and entrepreneurship (McFadzean et al , 2005; Zhao, 2005a;

Littunen, 2000; Cornwall & Perlman, 1990; Zahra, 1995; Hornsby et al , 2002; Ireland

et al , 2001), with some researchers putting this down to definitional ambiguity

regarding both concepts (McFadzean et al , 2005; Hornsby, 2002; Morris et al , 1994).

In addition, customer involvement remains an underdeveloped research area in the new

service development process (Alam, 2002; Alam & Perry, 2002; Johne & Storey, 1998).


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This research highlights the observation that, despite the health care industry's being

an excellent example of an industry with many opportunities for innovation and new

service development, it remains an underexplored area of research. This lack of

research is particularly apparent in the sector of mental health care, where customer

involvement in service development is of particular importance. Even though patients

are a critical actor in the service development process, users’ preferences and

competencies have not been widely explored. Moreover, the author has found that no

substantial research has been undertaken regarding entrepreneurship in the health care

industry. It would be useful to study how health care organisations choose to develop

new business ventures in order to deliver new service offerings.

1.4 Overview of the Conceptual Framework

This study follows a specific sequence of discussion that leads to the development

of its conceptual framework (see Chapter 5). The conceptual framework consists of

four key concepts, showing also the driving forces that push health care organisations

to innovate as well as the entrepreneurial and the new service opportunities that emerge

from the multiple combination of service innovation and corporate venturing and, on

the other hand, of new service development and customer orientation. Although these

key concepts have been derived from different disciplines and areas of research, it has

been essential to incorporate them into a study and also understand their influence in

the Greek health care industry. The rationale of integrating each of these key concepts

into the development of the conceptual framework is discussed in detail in Sections 5.4

and 5.5 in Chapter 5.

1.5 Contribution of this Thesis to the Area of Study

The results of this study could be advantageous to several parties. The following

table (Table 1.1) illustrates the contributions of this study, which were divided into two

parts based on their respective theoretical, practical and pedagogical functions (see also

chapter 12).


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Table 1.1 Contributions of the Study

Contributions of the study Beneficiaries

Theoretical contribution Researchers in the fields of service

innovation and corporate entrepreneurship

Mental health care sector in Greece

Practical contribution

Conceptual framework

New business development model

Strategic team and hospital executives of the

Euromedica Group

Doctors and other medical staff of the

Euromedica Group

Theoretically, the present study undertakes a critical approach to innovation and

entrepreneurship opportunities in the mental health sector, reflecting on joint ventures,

dissemination of expertise and knowledge, delegation of initiatives to multiple agents,

power sharing and research evidence. Together with developing a conceptual model for

innovation in mental health services, the need for change in organisational culture and

the strategies for the growth of user initiatives are considered. Taking a case study

approach, the strategies adopted by the Euromedica Group for market expansion and

leadership are analysed and are then connected to the internal structure of the

organisation. Current and emerging opportunities for corporate growth are identified

by board members, shareholders, management staff, and healthcare professionals. The

contributions of each of these agents is determining for the entrepreneurial mission

statement of the company. It becomes evident in the data analysis that although the

company consists of a dynamic and creative management team capable of identifying

growth opportunities and venues. They also have exhibited a solid knowledge of the

idiosyncrasies of the local market and have adapted their corporate plans to meet local

and national needs. They are now in the process of forming strong partnerships with

public bodies, pursuing opportunities for radical innovation.

At the same time however, there is the question of the influence of organisational

culture on strategic decisions. Greek organisations are reported to follow in their vast

majority a top-down approach to management, which makes it unlikely for Euromedica

to endorse an inclusive approach to the user movement. It is interesting thus to

investigate the attitudes and perspectives at different layers of management and

authority within the organisation and link these with the organisational structure of the

company. Obstacles in the organisational culture are identified and a new concept ofinnovation is outlined to include opportunities for new kinds of partnerships, customer-


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oriented services, and entrepreneurial growth. The argument for changing attitudes,

which will bring about more flexible and adaptable organisational structures and more

inclusive care services is formed.

This study reviews the relevant literature and develops a framework that

investigates and explores the level of patient involvement required for successful new

service development and how these new services could aid the organisation of new

establishment and growth in the sector of mental health hospitals. The purpose of this

study is, therefore, to investigate the influence of service user involvement on new

service development and how the outcome can enhance a firm’s entrepreneurial

activity, within the context of the health care market. This research responds to calls for

the further development and investigation of the concepts of customer participation in

the new service development process as well as of the link between innovation and

entrepreneurship (e.g. Jones & Rowley, 2011; Melton & Hartline, 2010; Alam & Perry,

2002; Matthing et al , 2004; Zhao, 2005a; Shaw et al , 2005). It also attempts to bring

the promising lens of entrepreneurship to the still emerging field of service innovation.

The main output of this study is the development of a conceptual framework within

which to examine how new service development contributes to corporate

entrepreneurship activities. More specifically, the conceptual framework devised in this

research contributes to the existing service development literature by providing

guidance on how to investigate the way health care organisations develop services that

meet the needs of their customers, whilst also identifying and capitalising upon

emergent entrepreneurial opportunities. This study also contributes to the discussion on

customer-oriented new service development. Customer participation in new service

development is a relatively new area of research, with few authors having discussed the

related benefits and potential issues. The current research work is the first to apply this

concept to the health care industry.

This study and the framework devised have highlighted the relationship and

interaction of innovation and entrepreneurship, and it is again the first of its kind to

apply this theory and discussion to the health care industry. Furthermore, it is found that

for organisations within this industry to be successful, they must adopt service

innovation strategies that will allow them the ability to identify entrepreneurial

opportunities. This framework represents a step forward in innovation and

entrepreneurship research as it provides a new insight into the identification of


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entrepreneurial opportunities through customer-oriented new service development in a

more integrated and systematic way than has been previously implemented.

In practical terms, this research complements the strategic and operational

framework of the Euromedica Group. Managerial implications involve, firstly, the

adoption of such service development processes as will be well-designed, organised,

and coordinated in such a way as to promote quality and innovation in order to increase

the chances of success. Secondly, it emerges that Euromedica lacks an appropriate

business culture and organisational structure, as there is insufficient cooperation

between the health units and central offices. The company needs to attain an

entrepreneurial behaviour that would build on the existing organisation, improve the

internal business climate, and enhance efficiency. Thirdly, Euromedica should develop

an innovation plan, adopt processes, and exploit resources that would advance

innovation activities, augment entrepreneurial opportunities, and improve

competitiveness. Lastly, it appears that the company considers patients as a useful

source of service improvement with regard to the residential services provided, though

it has not adopted procedures to integrate them with the new health service development

process. Euromedica needs to incorporate service users in its development activities in

order to develop offerings that fulfil customers’ needs and wants. For this reason, it

should adopt approaches and develop processes that take customers’ opinions into

account, so facilitating the firm's provision of customised services.

1.6 Overview of the Research Methodology

Considering all the above, qualitative research was conducted, following the advice

of Rohrbeck and Gemünden (2011, p. 234), who state, “for research fields that are

relatively new and about which the knowledge is limited, a qualitative research design

is recommended.” The study was implemented in three research sections. Each section

stressed the issues to be addressed. The first included in-depth élite interviews with

higher executives of the Euromedica Group, as well as with the administrator of each

psychiatric hospital. The aim was to investigate issues relating to innovation,

entrepreneurship, and customer orientation from the standpoint of management. The

second section comprised semi-structured investigative interviews with selected

medical staff of each hospital in order to examine issues, from a medical point of view,

involving the participation of users in developing and delivering services. The third


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section carried out semi-structured interviews with chosen patients from each hospital

to present the views and beliefs of mental patients about their own treatment and the

conditions under which they live. The main goal was the acquisition of a deeper

understanding of their positions and thereafter a comparison with the views of other

stakeholders.

Notwithstanding the fact that each section of the research is independent, together

they provide extensive and useful information from different angles. The information,

compared and combined, provides answers to important questions: how should patients

be involved in service development; what is the role of the client (and of the market) in

the development of health services in the Euromedica Group, and what is the opinion

of medical staff with respect to customer orientation, and what role do they play in

developing patient-oriented services? Therefore, the views of all kinds of stakeholders

are comprehensively appreciated, as regards the development of new customer-oriented

health care services and exploitation of business opportunities through corporate

investments. The interviews, in all the sections of the research, were conducted during

the period of December 2010 - March 2011.

Given that this research was carried out through semi-structured and exploratory

interviews, all sections of the research followed the same qualitative analysis process.

The main objective was to identify, investigate, and further compare the data collected

from all types of participants so as to achieve factual and constructive answers to the

research questions (Brown & Lloyd, 2001).

1.7 Overview of the Research Findings

1.7.1 Innovation Activity within Euromedica and its Mental Health

Hospitals

It is clear that senior executives of the Euromedica Group recognise the importance

both of the development of innovation and of entrepreneurial activity. Indeed, higher

executives identified many internal factors that stimulate innovation activity, such as:

the evolution of technology; the attitude of managerial and scientific staff towards

innovation; the evolving needs of patients; the quality of the service offerings; the need

to remain competitive and to have additional revenue from different sources in a time

of crisis. As an external factor that discourages firms from innovation, they identified

legislation, both financial and social. The management also claimed that tools are used


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to identify customer needs and assess the health market, such as adequate information

systems, questionnaires, and so on, despite the fact that these have not yet been

established in their psychiatric clinics. Informal, rather than formal, processes of

developing new services have been adopted. Moreover, there is some disagreement

between management and scientific personnel on the rationale for and the establishment

of a culture where continuous improvement is to be considered as a rule. The former

maintain that there are on-going efforts to develop a business practice where everyone

will be enabled to take initiatives to improve service quality, satisfy customer

requirements and reduce operating costs, while the latter reported that such actions are

having no effect and that the firm is falling short of expectations.

Nevertheless, all participants agreed that the role of both senior executives and

medical staff is critical in adopting innovation and in enhancing the process of services

development. There is room for improvement, though, as there are gaps in staff

participation in decision-making and cooperation with management. Despite this, it has

been found that the company is not rigorous in condemning efforts that fail, but prefers

to acquire knowledge from experience. In any case, few people claimed that the

company has created a system where innovation thrives without restrictions; most

respondents stated that further measures should be implemented to enhance the

organisation's structure and achieve better results. Participants argued that the stimulus

of development encourages innovative activity and Euromedica has shown that its

business goal is to expand its activities in all sectors of the health sector, and beyond

national borders, as well as developing new services that meet the growing needs of

customers.

This last is particularly important, as management observed that customers together

with other stakeholders lead innovation efforts. Therefore, they have developed

services that meet the needs of patients and take into account their demands. However,

the management team claimed that patients are able to play a role in enhancing

residential services in hospitals and stressed that only some users of psychiatric services

are able to contribute to the development process. However, there were respondents

who stressed that in psychiatric settings, there is no culture and organisation such as to

cater for the desires of customers and their integration into the process of service

development.


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1.7.2 Venturing Objectives and Entrepreneurial Activities of the

Euromedica Group

It becomes clear that Euromedica seeks to establish a well-organised network of

hospitals and health centres throughout the Balkans area, providing all kinds of healthcare services and meeting customer needs for high quality health care. More

specifically, the company aims to have a medical centre in each county (prefecture) and

an equivalent number in big cities. Moreover, one of their business objectives is to

develop a local network in each region, to include a general and obstetric clinic, a

psychiatric hospital, a physical rehabilitation centre, and an artificial kidney unit. This

network will form the basis for extending its activities to neighbouring countries.

As regards mental health, Euromedica Group plans to establish an association of

ten units and develop new structures for primary care. This has great value as the market

for primary care of mental health is quite underdeveloped and there is ample scope for

action. It also shows that Euromedica promotes business ideas that seem to take into

account both patient care and economic efficiency, encouraging investors/physicians to

own more than half of the shares in the new investment, increasing the financial

contribution where appropriate, and organising the new partnership, utilising their

knowledge and experience in the health sector.

1.7.3 New Service Development in Euromedica Neurological Services

Data show that Euromedica has developed in the last two years, inputting new

services, creating new departments and, collaborating with scientists to develop the

Group. In the field of mental health, it seems that two of the three psychiatric hospitals

have taken significant measures, through the upgrading of infrastructure and

enhancement of services or by developing new ones, in order better to meet needs and

improve their competitiveness. Furthermore, it appears that the company wishes to

expand its activities in the field of mental health by adopting new practices; establishing

new structures that will contribute to the treatment of patients and enhance

deinstitutionalisation, and utilising the knowledge and expertise of scientists to benefit

both society and its position in the market place. As regards the operation of the

hospitals, the plan is the expansion of services, aiming to gain more customers.

Overall, it appears that ideas for development mainly come from staff, the

competition, and the evolution of science; fewer are drawn from from customers and


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market research. It also appears that the coordination between departments in

developing new services is in need of improvement.

1.7.4 Customer Orientation and Health Services within Euromedica and

Its Mental Health HospitalsGenerally, it appears that Euromedica assesses the market, utilising a variety of

tools, such as statistics, reports, market research, observation of the competition,

cooperation with doctors, etc. Particularly in mental health, the company wishes to

collect information about: the demographic and social characteristics and the quantity

of potential customers; the socio-economic background; the status of the competition;

the cost of potential investments; economic benefits; and adequacy of the scientific

staff. Furthermore, Euromedica aims to establish solid relationships with doctors rather

than with customers. However, the customer viewpoint on services is taken seriously,

as special teams were formed within hospitals to improve services and increase

customer satisfaction. Moreover, despite all the shortcomings, the company is trying to

adopt techniques to monitor queries and complaints and to create mechanisms that

would integrate patients into the design of new services and lead to initiatives for

development.

Nevertheless, it is worth noting that although there is no great flexibility in adapting

the services already provided, many people support the involvement of patients in the

development of new services. Specifically, in mental health services it is evident that

hospitals make efforts to build a trusting relationship with customers by providing high

quality health care, arranging repeated sessions with psychiatrists and other doctors,

and maintaining constant communication with both patients and relatives. Still, it is

obvious that none of the hospitals uses specific tools to assess customer satisfaction or

respond to customer questions.

1.7.5 Patients and New Service Development in Euromedica Neurological

Services

First, it is important to note that the majority of patients surveyed preferred not to

be hospitalised, and seemed not to accept their psychiatric health ‘issue’. Few were

those who understood the need for help and even fewer were those who had decided on

hospitalisation. Nevertheless, respondents showed confidence in medical staff, noting

that they get comprehensive answers and feel safe in communicating their concerns and

fears. Only some have questioned the ability of physicians to provide appropriate


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treatment and indicated that they prefer to manage their concerns without assistance.

Moreover, many patients have confirmed the sufficient number of nursing staff and

noted that are satisfied with the overall service, indicating though that there is room for

improvement in the diet. In addition, participants argued that the behaviour of staff is

appropriate; they therefore feel comfortable discussing a personal matter or sharing

their thoughts. Respondents were positive about the facilities of the hospitals, namely

the condition of the buildings, environment, amenities, etc. There were some, however,

who indicated that further improvements should take place.

Beyond that, participants said that they enjoy participating in activities, as these

strengthen their treatment and help them overcome their health difficulties. Moreover,

it is revealed that a large number of stakeholders were willing to participate in decision-

making regarding their health care. They recognised that this would be extremely

beneficial for the development of treatment and so for their psychological condition.

Only some argued the opposite. Still, it is noteworthy that in two hospitals, patients had

not so far been invited to comment on the services provided.

Nevertheless, many respondents argued that it would be exciting to join a

programme in which they could express their beliefs and perceptions about treatment,

so they are willing to contribute further to improving services. Furthermore, they agreed

that they should be employed to work in the hospitals, as this would be beneficial to

their health and would make them feel useful and creative.

1.8 Research Structure

Overall, this study comprises twelve chapters, which are briefly described below.

Fig. 1.2 illustrates the structure of the research.


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Figure 1.2 Structure of the research

The second chapter focuses on the health care market, considering both demand and

provision. In particular, it encompasses general information on the Greek health care

industry, such as the structure of health services in Greece, the characteristics of the

industry, health expenditure, and an overview of the mental health care system of

Greece. With regard to the demand and provision of private health services, this chapterincludes the characteristics of and the factors affecting the demand for private health

services, as well as the development of its infrastructure and industry structure; the

conditions of competition, and a presentation of the private health care corporations. In

addition, the chapter describes the private health care market in Greece in terms of

domestic market size and the market shares of the health care groups. Finally, it gives

a profile of the Euromedica Group and Euromedica Neurological Services.

The third chapter reviews the literature and theories of service innovation,

entrepreneurship, and corporate venturing. Specifically, it defines service innovation,

Chapter 1

Introduction

Chapter 9 Chapter 10

Analysis of

Thermaikos Hospital

Analysis of

Castalia Hospital

Analysis of

Galini Hospital

Chapter 7

Analysis of

Senior Executives

Chapter 8

Chapter 2 Chapter 3 Chapter 4

New Service Development

& Customer Orientation

Research

Context

Service Innovation &

Corporate Entrepreneurship

Chapter 5Conceptual

Framework

Chapter 6Research

Methodology

Chapter 11

Review of

Key Findings

Chapter 12Conclusions

Chapter 1

Introduction

Chapter 9 Chapter 10

Analysis of

Thermaikos Hospital

Analysis of

Castalia Hospital

Analysis of

Galini Hospital

Chapter 7

Analysis of

Senior Executives

Chapter 8

Chapter 2 Chapter 3 Chapter 4

New Service Development

& Customer Orientation

Research

Context

Service Innovation &

Corporate Entrepreneurship

Chapter 5Conceptual

Framework

Chapter 6Research

Methodology

Chapter 11

Review of

Key Findings

Chapter 12Conclusions


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highlights the importance of service innovation strategies, and identifies related

processes. Further, it focuses on entrepreneurship and its types and portrays the

dimensions and characteristics of corporate venturing.

The fourth chapter reviews the literature and theories of both new service

development and customer orientation. It defines new service development and

presents the types of, characteristics of, and critical factors for new service

development. It also illustrates the strategies and the processes of new service

development, with an emphasis on models for health service innovation. The chapter

also defines customer orientation, underlining customer roles in service innovation and

customer involvement in the health care industry. Lastly, it points up the processes for

customer orientation development.

The fifth chapter combines the theories of both corporate venturing and innovation

and customer involvement in new service development. It stresses the relation between

corporate venturing and service innovation and illustrates the models that combine the

two terms, or conceptualisations. It also draws attention to the importance of customer

participation in new service development activities. Finally, it develops the conceptual

framework for new service development through corporate venturing in health care,

applying the theories from chapters 3 and 4.

The sixth chapter discusses the methodology of the present research. It clarifies the

rationale for preferring qualitative research methods and describes the process of the

primary research. As noted earlier, there are three research sections in this chapter:

corporate and hospital; medical staff; patient-related research. These comprise the

totality of the research. Each section consists of:

the research objectives and questions;

data collection methods;

survey instruments;

samples;

data analyses; and

limitations of the research methods applied.

The seventh chapter is introductory to the analysis section of this research. It

examines the results of the élite in-depth interviews completed by top executives -

members of the decision-making team - of the Euromedica Group. The aims of this

chapter are to present the innovative activity of the Group in general, the tools and the


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processes employed to develop new health services, the entrepreneurial model used by

Euromedica to expand its operations, and the strategy followed on customer

involvement in developing new offerings.

Chapters Eight to Ten investigate the operation of three mental health hospitals,

case-by-case. Each chapter falls into two parts. The first examines the views of both

administrative and medical staff regarding the factors that determine innovative

activity; the tools and the processes applied for new service development; the

contribution of customers and the role of executives and medical personnel into the

innovation process and the customer involvement in new health service development.

The second part explores the perspective of patients regarding hospital’s operation and

infrastructure along with their enthusiasm to be a part of the service development

process.

The eleventh chapter summarises the key findings of three sections of the research

and includes a cross-case synthesis. The twelfth and concluding chapter evaluates the

research findings and considers the contribution of this research to the field of study. In

particular, it relates the innovation and corporate venturing literature to theories

concerning new service development and customer orientation, resulting in the

development of a distinct conceptual framework. Implications of the findings at firm

level are also discussed, to suggest future research directions. The limitations of this

research are also discussed.


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Chapter II

Research Context: Overview and Development of the Private

Health Care Industry in Greece

2.1 Introduction

The introduction of the National Health System (NHS) in 1983 set the basis for the

provision and distribution of both public and private health services in Greece. The

objective of this chapter is to explore the Greek private health services market and more

specifically, the sector of mental health, including addictions (substance abuserehabilitation). The chapter also includes the general characteristics of the industry, the

factors that affect the demand for private health services, and the supply of health

services by private health groups. The size of the health services market is presented,

with the market shares of the leading groups. The Euromedica Group's company profile

is presented, as well as the prospects of the Greek health care industry.

2.2 Overview of the Greek Health Care Industry2.2.1 The Structure of Health Services in Greece

The structure of the Greek health care system in the basic levels of health care is

as follows (W.H.O., 1996) (Fig. 2.1):

Primary Health Care: is also called outpatient care and covers services

concerning the prevention and diagnosis without requiring the patient to stay in

hospital. This level of care is covered by:

Public health centres, hospital outpatient departments and insurancefunds;

Doctors; professionals in their private surgeries;

Microbiological Laboratories;

Diagnostic Centres;

Private outpatient clinics.

Secondary and Tertiary Health Care: This refers to services for patients who are

hospitalised in hospitals or clinics as offered by: a) 144 public hospitals of the NHS and outside the NHS (military, S.I.I.) and 196 private hospitals (Health


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Units Company data, 2004).

Emergency Medical Care: This is provided nationwide by the National Centre

for Emergency Aid (Ambulance Service).

Psychiatric Care: Apart from the psychiatric hospitals in the public and private

sectors, mental health care is also supported by the psychiatric departments of

general hospitals and a network of outpatient and community structures in the

public sector.

Table 2.1 shows the number of hospital beds per 1,000 habitants accounted for in

the censuses 1991 and 2001 by geographic region. According to the figures in the table,

some improvement is noted for the regions of Epirus, Thessaly, Thrace, Crete, and

Central Greece.

Fig. 2.1 Organisational Chart of Health Care System (source: W.H.O., 1996)

Government

Ministry of Labour

& Social Insurance

Deputy Ministry of

Social Insurance

Social Insurance Funds

Social Insurance Institute

(S.I.I.) urban polyclinics

Ministry of Health

& Welfare

Under-Secretary

of Welfare

Social Services

Direct Health

Directorates

Under-Secretary

of Health

General Directorate

of Public Health

Private HospitalsRegional Hospitals

District Hospitals

Health Centres

Rural Clinics

Central Health

Council

Government

Ministry of Labour

& Social Insurance

Deputy Ministry of

Social Insurance

Social Insurance Funds

Social Insurance Institute

(S.I.I.) urban polyclinics

Ministry of Health

& Welfare

Under-Secretary

of Welfare

Social Services

Direct Health

Directorates

Under-Secretary

of Health

General Directorate

of Public Health

Private HospitalsRegional Hospitals

District Hospitals

Health Centres

Rural Clinics

Central Health

Council


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Table 2.1 Complement Indicator of Hospital Beds (1991 & 2001)

Region 1991 2001

Aegean

Islands5.0 4.1

Greater

Athens7.0 6.1

Epirus 3.7 4.3

Thessaly 3.2 4.0

Thrace 2.5 2.8

Ionian Islands 4.9 4.5

Crete 4.8 5.0

Macedonia 5.1 5.0

Peloponnese 3.0 3.0

Central

Greece1.9 2.6

Total 5.0 4.8

Number of beds per 1000 habitants

Source: Hospitals, N.S.S.G.

2.2.2 General Characteristics of the Industry

According to the World Health Organisation (1996), the majority of private

hospitals for secondary care operating in Greece are classified among those whose

capacity is from 41 to 100 beds, and there are also private hospitals which offer from

100 to 300 beds. Depending on their size, private general hospitals are divided into the

following categories: Large multi-clinics, which are located in Athens and Thessaloniki, and are few

in number. These clinics exceed 300 beds and the majority of them are staffed

by highly trained and skilled medical staff, deploying high-tech medical

equipment. They maintain agreements with insurers and public insurance funds,

and with most insurance companies in the private sector. These clinics cover a

wide range of services, including prevention and diagnosis.

Medium-sized clinics, which also usually maintain contracts with private

insurance companies and the public funds.

Small clinics, most of which cover the cost of hospitalisation of their patients

(in whole or part) via contracts with various public insurance agencies.

Neuropsychiatric clinics, which are a separate category, are sufficient in number

and their revenues come entirely from internal patients, with a high average

annual occupancy.

As for the geographical distribution of private clinics, the majority are around the

region of Greater Athens, followed by the region of Thessaloniki. In recent years, there


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have been transformations in the private hospital sector, since small regional units have

consolidated with larger ones. Furthermore, in some cases, large units in the industry

became international by expanding their operations in foreign countries. An example is

the Athens Medical Centre, which has expanded its activities in various countries of the

Balkan area. The difficulty of the smaller units in responding to the rapid development

of medical technology and also the high cost of construction and equipment for new

treatment units are the two main reasons for the strategic acquisitions - mergers –

consolidation of the smaller firms.

2.2.3 The Mental Health Care System in Greece: An Overview

Traditionally, Greece’s mental health care system constituted of a network of state

psychiatric hospitals where patients were institutionalised. The development of this

system occurred during the 19th and the 20th century, when "asylum" units were

established. In 1832, Greece had no specialised care units for mentally ill people, who

received only informal treatment from their families or the church (Ploumpidis, 1989).

The first mental health care institutions were founded on Corfu by the British, who

handed the island over to Greece in 1864. Corfu’s hospital initiated biomedical

psychiatry and was the paradigm for future infirmaries (Blue, 1993). The Dromokaition

was established in Greater Athens in 1887, while at the beginning of the 20th century a

network of mental institutions were developed in Crete, Thessaloniki, and Athens. At

the end of the Greek Civil War (1946 – 1949), five psychiatric institutions composed

the central part of Greece’s inpatient mental health care. By the late 1950s, the rise of

private clinics and facilities was noted in Athens, Thessaloniki, and other large regional

cities (Ploumpidis, 1989).

Nevertheless, as Blue (1993, p. 306, 308) states, “the Greek government has

reinforced the prominence of the large mental hospital in the Greek psychiatric care

system through limited financial support for services, the absence of a national mental

health policy, and psychiatric legislation and (…) it has been minimally involved at

economic and policy levels in the creation of psychiatric care services other than mental

hospitals”. This is in conformity with Madianos et al (1999b, p. 170), who note that

“centralization of psychiatric care with an absence of community mental health services

and of psychiatric beds in general hospitals; (2) uneven regional distribution of services

in the country, leaving some regions without access to psychiatric care, and (3)


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inefficient management of resources and lack of qualified administrative staff (…) was

totally inadequate to meet the psychiatric morbidity needs of the population”.

According to Stefanis et al (1986), Greek mental health transformation was

initiated in 1984 using funds from the European Community. That reform included the

development of new structures, such as mental health prevention services at community

level and psychiatric departments in general hospitals; the reduction of resident

psychiatric patients through the development of alternative modes of care, and the

improvement of service quality and living conditions through the training of mental

health personnel (Madianos et al , 1999b). At the same time, most mental patients start

their treatment in a private setting. Estimates show that more than 80% of those

hospitalised in a state hospital had formerly been in a private clinic (Blue, 1993).

Furthermore, Greek psychiatry has not assisted in the development of proper treatment

and settings over time as it mirrored, until recently, the notion that institutionalisation

is the appropriate handling for the ill.

However, there were some efforts in the past, by Greek governments with the

cooperation of experienced academics, to introduce new methods to enhance service

quality and delivery. A day hospital was launched in Athens with a 24-hour emergency

system (Mantonakis, 1981), two community mental-health centres were established, in

Athens and in Thessaloniki (Madianos, 1983; Manos & Logothetis, 1983); psychiatric

departments in general hospitals were developed across the country and long- and short-

stay homes have been set up to assist in deinstitutionalization (Blue, 1993).

More recently, a national programme, named ‘Psychargos’, was initiated in order

to improve the quality and specialisation of services provided to patients (Madianos et

al , 1999a). The first phase of the programme was executed in 2000 – 2001, where each

prefecture of the country houses a psychiatric facility, with Athens and Thessaloniki

having more than one (Bellali & Kalafati, 2006). More specifically, this phase should

introduce new organisations for community-based care, such as: half-way houses;

nursing homes and outpatient units; upgrading of public hospitals’ facilities; operation

of novel intervention and community after-care schemes, such as vocational workshops

to train patients; and training programmes in psychosocial rehabilitation for mental

health personnel (Grove et al . 2002). The second phase of this programme has been

running since 2002 until today and includes more initiatives, including:

Integrated psychiatric and paediatric psychiatry clinics in general hospitals,

including short-term inpatient units and a crisis intervention centre;


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Day care centres for adults, adolescents and children;

Customised psychiatric services to the target group;

Ambulatory mental health units in areas with particular problems of access such

as islands and mountainous regions; Mental health community centres for adults and child guidance centres for

children and adolescents;

Counselling services to meet the needs of families caring for the mentally ill

(Grove et al . 2002, Madianos 2002).

‘ Psychiatric Reform’ in Greece

‘Unfulfilled reform’, ‘incomplete effort’, ‘neglected priority’ are some of the

characterisations attributed to or associated with Greek psychiatric reform, which has

already been in progress for two decades, but has not matched the hopes of those who

believed in a change in how to tackle mental health problems. Even the question of

funding, despite its undoubted importance, is only one side of a multifaceted problem,

the solution of which requires serious administrative and institutional interventions.

From an evaluation of progress so far, it can safely be said that psychiatric reform has

not been established in Greece and has not eliminated the asymmetries and inequalities

in the provision of mental health (Sakellis, 2009). Although it should not be overlooked

that progress has been made (such as structures in the community, transformation of

psychiatric hospitals, etc.), the following issues remain:

a system of service quality assessment on the part of public entities and private

legal entities, profit and non-profit,

connection of the funding of the mental health structures with the findings of

the evaluation,

updating public policy on Mental Health in order to delineate the objectives of

the state and the actions of bodies,

updating and completing the legal framework, taking into account the White

Paper of the European Union and the perceptions of both the World Health

Organization and the World Association for Psychosocial Rehabilitation,

a decisive role for the Sectoral Committees of Mental Health, maintaining their

operation and promoting service networking in each area,

staffing of all bodies and

consistent and adequate funding of all actions to ensure continuity of care.


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Furthermore, the following issues were revealed from the interactions and the

positions developed in a conference entitled ‘The child with mental health problems:

The right to psychosocial rehabilitation", organised by the Greek Ombudsman (5 th

February 2009):

lack of facilities for young people in need of urgent treatment (child and

adolescent psychiatry),

lack of structures for psychosocial rehabilitation of children and adolescents

with mental health disorders or other serious problems that require medical

rehabilitation,

serious malfunction of private non-profit bodies and delays due to reductions in

funding.Resolving these issues is crucial to improve the quality of care for people with

mental health problems and to provide greater protection of their rights. However, no

policy on mental health can be successful if not accompanied by measures that combat

the stigma of mental illness and social prejudices. At the same time, it is necessary to

develop a support system for those families that have a mentally ill member

(Stylianidis, 2009).

Psychiatric reform regards the safeguarding the rights of people with mental health

issues and the role this can play both as a philosophy for the modernisation of services

that are focused on the asylum, and as a model for launching relevant procedures across

the Balkan region (Henderson, 2009). Although the value of psychiatric reform is

recognised, its evolution so far has proven incomplete. This emerged from the

conference ‘Psychiatric Reform in Greece: Requirements, recommendations and

solutions’, organised by the Greek Ombudsman in March 2009 (Sakellis, 2009). It was

also highlighted that:

1) Psychiatric reform is not well established in Greece. It was emphasised at the

conference that there lacks a movement which would focus on the cooperation of

workers in mental health care with patients and their families. It is worth noting that

individual initiatives cover the absence of a comprehensive state response of

institutional shortcomings and problems.

2) Current progress in mental health reform was rated as ‘ perverse’ because:


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i. the reduction of psychiatric beds combined with the lack of alternative

community services resulted in dozens of makeshift beds in psychiatric

hospitals and psychiatric clinics in general hospitals

ii.

it has not yet achieved the desired ideological and institutional change thatwill lead to the disappearance of the concept and practice of detention and

other restrictive methods,

iii.

the power relations with patients have not been reshaped in such a way as

to transform them into subjects of change,

iv. the rationale and practice of the inpatient bed, either for housing or for

treatment, continues to dominate at the expense of support and alternatives

to ‘the asylum’.

3) The absence of longstanding and precise planning and the lack of guidelines on key

issues were identified in official mental health policy. In addition, the parallel

existence of the immunity system and care services in the community is regarded

as problematic, while the lack of prevention, the inadequate accessibility to health

services and the poor quality of care were reported as ‘chasms in mental health’.

4) The issue of ‘segmenting’ mental health services is regarded as important. Both the

rudimentary network of outpatient services with inpatient units and the inadequate

horizontal communication between the outpatient services cause major difficulties.

5) Mental health of children and adolescents is assessed as a neglected priority. In

particular, many in the conference noted that:

i.

research funding is inadequate in Child Psychiatry and this is not a subject

in education,

ii. there is a shortfall in relevant structures for mental health care in Greece.

Overall, from the 400 units that were provided under the scheme

‘Psychargos’, only ten are for children and adolescents. What is more, the

65 mental health facilities for children and adolescents set up in the last 25

years are unevenly distributed and so do not provide coverage for the entire

country,

iii. the existing structures are understaffed or barely functioning due to limited

funding. There is also a shortage of inpatient hospital units (40 beds in

Athens and Thessaloniki), while there is a lagging behind in developing


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new structures as well as structures for day care (e.g. for young people with

autism),

iv. there are no organised and well-coordinated prevention programmes.

It must be understood that every action that delays Psychiatric Reform does notharm simply the mentally ill and their families, but works against the entire project of

reform in the area of social solidarity and acts against the people, social action, and the

richness of diversity in social aggregation (P. Giannoulatos, personal communication,

March 9, 2011).

2.3 Doctor and Patient: Is it a Relationship were the Doctor is the

Provider and the Patient is the Consumer or Vice Versa?2.3.1 Parsons’ Perception of Doctor-Patient Relationship

Parsons’ (1951) perception of the relationship between the doctor and the patient

is claimed to be an ‘ideal type’ model, which abstracts and presents what are considered

to be the fundamental features of a particular social organisation or social role, as well

as is an valuable method of analysing and describing very complex social phenomena.

Parsons depicted four general expectations that are entailed to the role of sick people;

as sick people are allowed, and might even be required, to give up some of their normalactivities and responsibilities, such as going to work or getting involved in physical

exercise, and additionally, they are regarded as being in need of care. The above two

expectations and privileges are, however, contingent on the sick person fulfilling the

third and the fourth obligations of wanting to get well as quickly as possible, and of

seeking professional medical advice and, most importantly for the doctor – patient

relationship, cooperating with the doctor, respectively.

Parsons highlights that the specific expectations of the sick person, as for example

the number and type of activities the person is expected to give up, will be influenced

by the nature and severity of the condition, since it is recognized that not all illness

requires people to abandon their normal social roles and occupy the status ‘sick’. For

instance, minor illness can be managed without recourse to the doctor and does not

involve any changes to a person’s everyday life. Correspondingly, people with a chronic

illness may have the need to consult the doctor regularly; however rather than

occupying a permanent sick role, they are usually expected to try to achieve their

maximum level of functioning and to acquire the status ‘sick’ only in cases of a change


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in their usual health. Consequently, it is obvious that Parsons viewed the role of the

patient as a temporary social role that has been instituted by society, which aims to

return sick people to a state of health and restore them to fully functioning members of

it as quickly as possible. Finally the role of the patient is also considered to be a

universal role which has its obligations and expectations that apply to all sick people,

regardless their age, gender, ethnicity, occupation or status in other spheres.

On the other hand, the role of the doctor is viewed as complementary to the role of

the patient. As the patient is expected to cooperate fully with the doctor, doctors are

expected to apply their specialist knowledge and skills for the benefit of the patient, as

well as to act for the welfare of the patient and community rather than in their own self-

interest. Doctors are also supposed to be objective and emotionally detached, and also

to be guided by the rules of professional practice, as the conformity with these general

expectations is a vital requirement in order to carry out the tasks of diagnosis and

treatment, and most importantly when this process involves the need to know.

2.3.2. New Terminology

As mentioned earlier, Parsons’ theory of both the roles of the patient and the doctor

is the ideal one and does not apply in reality, where, on the contrary, doctors are

considered as the providers while the patients are regarded as customers. According to

Hartzband and Groopman (2009), the root of this new vocabulary is a result of both the

industrialisation and standardisation of medical care in order to achieve cost control.

The relationships between doctors, nurses, or any other professional in the field of

medical care and the patients are determined mainly in terms of a commercial

transaction, as the consumer or customer is the buyer and the provider is the vendor or

seller, because of the financial aspect of the clinical care. However, it is claimed that

this is only a small part of a much larger whole, and to patients, it is the least important

part. There has been a lot of debate concerning the relationship between the medical

care professionals and their patients, and its commercialisation. Most of them are with

regard to high-deductible health policies and budget plans for clinical care that assume

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