On the sectorization of psychiatric services.

Sectorization, the organizational principle of dividing the population into geographic sectors and developing all necessary public hospital and outpatient services within each sector, emerged as part of the broader movement to reform psychiatric services in Europe as early as the 1950s. In France, sectorization began in the 1960s through the joint management of hospitals and new outpatient services and was institutionalized by 1985 laws establishing sectors for 75,000 residents for adults and 150,000 for children and adolescents, today numbering 830 across the country.1 Another form of sectorization evolved concurrently in the United Kingdom through the development of community psychiatry and later the establishment of mental health trusts.2 Since then, sectorization has been adopted in most European countries,3 while in some, like Belgium, community psychiatry has been linked to primary healthcare services.4 Sectorization aims to facilitate service accessibility and continuity of care, contributing to the reduction of hospitalizations and readmissions. International experience indeed shows that the implementation of sectorization has been associated with many achievements of community psychiatry 3 and that it has significant long-term positive outcomes for the users of mental health services in terms of functioning and met needs.5 In all countries, as expected, there was a gradual transition from the development of units with specific catchment areas to the full establishment of a sectorized system with administrative, managerial, and operational efficiency. In some countries, despite earlier declarations, its implementation progressed only in recent years, as in Portugal 6 and Greece.7 Additionally, in recent decades, the expansion of community- based interventions has brought about complex problems in the liaison of various service units and the issues caused by the widening gap between growing needs and cuts in public funding. In Greece, Law 2071/1992 and Framework Law 2716/1999 designated sectorization as the organizational principle of public psychiatric care, while Law 2716/1999 also introduced community mental health as a core principle. However, deinstitutionalization remained the central axis of the reform for a long time, rather than the development of community mental health units, and thus the implementation of sectorization lacked adequate support in practice. 7 Ιn 2019, 38 adult sectors (11 in Attica) and 17 child and adolescent sectors (4 in Attica) were registered, accommodating populations of 250-300,000.8 However, only a few sectors provide an adequate range of services. The deficiencies lead to bypassing sectorization, especially regarding hospitalizations, and widespread use of private services. This situation undermines continuity of care and contributes to relapses and high rates of involuntary hospitalizations, especially in Athens. Within mental health sectors in Greece, include public hospitals and outpatient services as well as many residential and outpatient care units of NGOs. The lack of units' coordination, liaison, and synergy in each sector became evident with the failure of the Mental Health Sectoral Committees established by Law 2716/1999, which only had advisory roles. Law 4461/2017 provided for the establishment of managerial boards of mental health sectors within the health regions, and regional inter-sectoral councils were also established, but its implementation did not continue. Sectorization did not solve the problem of readmissions. For example, in the Psychiatric Hospital of Attica, readmissions within one year currently range from 41% to 45% of total admissions.9 However, it gave prominence to the central role community psychiatry can play in the prevention, treatment, and social integration of the most severe cases. However, for its completion, beyond administrative and managerial arrangements, it was necessary to address severe shortages in public services, particularly in hospital beds and staffing of mental health centers, so they could fully meet the various needs in each sector. Additionally, psychosocial rehabilitation interventions remained limited and practically not sectorized. During the pandemic and afterward, the weakening of public services continued, while most of the new projects were given to NGOs and mainly focused on specialized interventions, such as early intervention in psychosis, psychogeriatrics, and autism care. The entire process underscored the urgency of a preliminary study of needs at a national level and by sector, as well as of advancements in coordination and liaison between different units. The principle of sectorization was maintained in the 2021-2030 National Action Plan for Mental Health.10 However, today we face an unprecedented administrative and organizational framework introduced by Law 5129/1.8.2024, which attempts two major shifts. First, it centralizes the management of all psychiatric services in the new Regional Management Board of Mental Health Services in each of the seven health regions. Second, it centralizes the management of all different services for addictions under a private-law entity called the National Organization for the Prevention and Treatment of Addictions. It, therefore, proposes a massive organizational reorganization entrusted to regional management in each health region while abolishing articles from previous laws on the sector-based organization. It's worrying that these newly established boards will be in charge of all psychiatric units in a "mega-sector" with huge operational needs that didn't seem to have been planned for. Similarly, the immediate abolition of the organizational structures of major psychiatric hospitals in Attika and Thessaloniki without necessary provisions to address potential operational issues is troubling. The effective operation of mental health service units cannot be achieved without specific catchment areas and a clear organizational structure. Thus, contributions of managerial and scientific leaders of the various units, as well as of scientific/professional associations, are needed for substantive clarifications and amendments in the implementation of this new law consistent with the essence of sectorization.