Greater Poland: piloting of mental health centers under the magnifying glass of the NIK

Since the start of the pilot in 2018, the National Health Fund has struggled to account for the funds. In Greater Poland, an audit by the Supreme Audit Office (NIK) found that the amounts to be reimbursed were underestimated by PLN 4.4 million between 2020 and 2023.

The provincial branch of the National Health Service discovered that medical facilities were unreliably assessing staff availability. It was assumed that medical staff could work from 99 hours per week up to 249 hours - recall that a week has 168 hours. The NFZ's lack of control over the reported capacity of the facilities resulted in irregularities - both CZPs were found to have staffing that did not agree with the terms of their contracts.

At the hospital in Zlotow, some physicians provided services for nearly twice as much as declared in the contract with the National Health Fund, and for a period amounting, in the most extreme case, to more than 100 hours without breaks. Such an organization of work raises doubts about the possibility of ensuring adequate quality of health care services and, consequently, the health safety of patients, as well as doctors.

The same CZP did not meet the standards for nurse staffing set by this hospital. In addition, a doctor on duty in the psychiatric ward was not set aside for the center, outside of "ordination hours" (i.e., from 7:30 a.m. to 3:05 p.m.), which was in violation of the pilot regulation.

Also at the same entity, the working time schedules of contracted physicians were arranged in such a way that the time required to perform several different medical services for the hospital overlapped. This caused the doctors to perform either one service in its entirety or several of them under the required working hours, while being paid in full for each of the aforementioned services. As a result, the doctors were paid more than PLN 253,000 for providing services during duplicated working hours. In addition, in the entity, which is a medical entity of the public finance sector, an unfavorable amendment was made to the contract concluded with the doctor for the hospital, which violated the provisions of the Law on Medical Activity, which resulted in an additional cost of PLN 89 thousand. It should be added that in 2020-2022, the proper working time schedules of contracted physicians were not maintained, and the working time schedules of psychologists and clinical psychologists of community/occupational therapists were maintained in a manner that did not comply with the provisions of the Pilot Regulation.

Violation of direct coercion rules

At the audited hospital in Zlotow, decisions to extend the use of direct restraints were made by doctors who were not authorized to do so. When immobilizing patients, the statutory obligation of doctors to conduct a personal examination of the patient was not observed when approving the next period of application of this measure. In addition, approvals for extending the use of this restraint were made after the expiration of the periods specified in the regulations. Meanwhile, it was illegal to leave immobilized patients, after the period for which the coercion was ordered by a doctor and without extending its application for another period. The recorded longest case of direct coercion applied was 42.5 hours.

The same hospital also found a blatant violation of the right to respect for intimacy and dignity during the temporary release of a patient who had been subjected to direct coercion in the form of immobilization. This is because the patient was led naked out of the room into the corridor and then also brought back naked. The Head of the CZP was not aware of the reasons for this procedure, but she testified that "none of the patients ever complained about being led out of the room naked."

Inadequate housing conditions

In one CZP (hospital in Zlotow), the premises conditions violated the requirements set forth in the 2019 Regulation of the Minister of Health on the detailed requirements to be met by the premises and equipment of the entity performing medical activities. There was a lack of rooms fulfilling the function of diagnostic and treatment rooms. As a result, necessary examinations were carried out, among other things, in a doctor's on-call room or a doctor's room located outside the wards, or in patient rooms after the other patients had left them. Therapies were conducted not only in therapy rooms, but also in patient rooms, the cafeteria and the courtroom. In addition, the number of places in the psychiatric day ward was insufficient and did not meet the requirements of the pilot regulation.

The prevailing conditions in the sanitary facilities at this CZP did not allow patients' rights to intimacy and dignity to be fully respected. In the bathrooms, showers were not separated by permanent partitions, and in the men's bathroom, shower areas were not separated at all. In the toilets (in the observation and diagnostic sections), the toilet bowls were separated by walls, but no doors or curtains were installed there. In addition, there were numerous stains on the ceilings and walls of the toilets, and even mold on the walls and ceiling in the women's restroom. It should be added that the sanitary facilities in the psychiatric ward were not adapted for people with disabilities.

CZP's mismanagement

The audit also found irregularities involving wasteful spending of public funds by medical entities. In one of them (Institute of Psychoeducation Ltd.), it was found that funds from the pilot contract were used for other purposes and the same expenses were settled twice, thus overstating costs by PLN 65.7 thousand, and was in violation of regulations.

In Zlotow hospital, on the other hand, it was found that the Director received a salary higher than allowed by regulations, which resulted in him being paid 128.6 thousand zlotys more from September 2021 to December 2023. Part of this amount came from funds allocated for CZP activities.

Development of community care

The number of patients receiving community care varied widely. CZPs were establishing cooperation with various community care centers, which, in the case of one Center, made it possible to provide more care to those in need. However, the lack of adequate system solutions made it difficult to cooperate with psychiatric hospitals, which was important for the continuation of patients' treatment after hospitalization. The CZP in Zlotow did not organize self-help groups for patients and their families. Shortly after the establishment of the following groups in 2020: psycho-educational group for families of people with mental disorders and diseases; psycho-educational group for people suffering from psychotic disorders and for people with anxiety-depressive disorders, they were liquidated during the COVID-19 pandemic and did not resume their activities due to the lack of suitable premises.

The irregularities detected by the NIK led to two notices to the prosecutor's office. These included the unauthorized use of direct coercion and the falsification of personnel time accounts.

Source: NIK