Health Care Services for the Mentally Ill: Eastern & Western Cape Departments of Health

Meeting report

The Chairperson referred to the 2017 Health Ombuds Report about the patients of Life Healthcare Esidimeni Hospital in Gauteng and how, in the light of that report, it is vital to raise any problems in advance and learn lessons from it. The Committee was starting with reports from the provinces, and afterwards would conduct its oversight.  The Department of Social Development had also been invited because social services and health services are intertwined. She thanked the leadership provided by the Ministers of Health and Social Development and the Premier of the Eastern Cape.

Ms Jeanette Hunter, Deputy Director General: Department of Health, and Dr Melvyn Freeman, Chief Director for Non-Communicable Diseases attended on behalf of the National Department of Health  

Eastern Cape Department of Health (ECDoH): Health care services for mentally ill patients
The Eastern Cape delegation included Dr Pumza Dyantyi, MEC Health ECDoH; Dr Litha Matiwane, Chief Director: Hospital Services, ECDoH; Dr Patrick Maduna, Deputy Director General ECDoH; and Mr T D Mbagane, HoD: ECDoH; Ms Nomfesane Nyatela, Parliamentary Liaison Officer: ECDoH.

Dr Pumza Dyantyi, MEC Health ECDoH  thanked the Committee for the opportunity to present the status report on mental health services in the Eastern Cape, and asked Dr Matiwane to present it (see document).

Dr Litha Matiwane, Chief Director: Hospital Services, ECDoH, said the report consisted of an overview of mental health service norms covering acute psychiatry, medium to long term psychiatric care, and community care: 4 000 beds in total are provided. The platform of care includes:
- Primary Health Care with community-based services
- District hospital services with 72-hour services
- Hospital management services with acute and chronic in-patient management.

Challenges and mitigation:
There is a 1 600-bed shortage in the Eastern Cape, and most of the beds are concentrated in the western part of the province. Plans to mitigate these problems are to open 30 beds at Libode, to increase acute beds and to prioritise the eastern part of the province. The burden of disease shows a radical increase in substance abuse, which requires a social service of rehabilitation. This has become a critical need. There are only two public facilities in the Eastern Cape to deal with substance abuse.

Forensic patients:
There are currently 94 state patients awaiting admission and 261 awaiting observation. This is being mitigated through the addition of 30 beds at Komani Psychiatric Hospital and the use of Komani for observation. This will also improve the waiting times.

Human Resources:
The number of filled posts are 1 606 and 239 remain vacant (e.g. psychiatrists, social workers, etc).
Budget allocations per facility were provided.

Analysis:
Due to the shortage of beds and substance abuse rehabilitation centres as well as the unfilled posts, there is pressure on the available beds:
• Full beds, with the average at 97% being way above the 85% norm;
• Occupational therapists offered lucrative packages by the Department of Education so DoH is short. There is the need to increase bursaries.
• Reflects in overflow in casualties and adverse events
• The bulk of the capital budget is in Programme 8 (Infrastructure).

Corrective actions:
Standardised protocol has been established
40-bed unit being opened at PE Provincial Hospital
60 beds to open in central part of the province
30 beds to open in September at Libode increasing to 90 beds in the eastern part of the province with an additional 120 planned.

There are three review boards, located in Port Elizabeth (western), Queenstown (central) and Mthatha (eastern). Each board has three members: a health care professional, a legal expert and a community member. The boards' function is to protect patients on their journey from a listed facility to involuntary admission through the courts. They ensure that patients’ rights are not infringed, and there are structures whereby the patients and their relatives can complain about the correctness of the admission process.

Dr Dyantyi stressed that the challenge of finding occupational therapists has been discussed with the Department of Education. The DoH wants to attract more people back to serving their communities and so wants to concentrate on offering more bursaries.

Dr Matiwane said that they have very strong views about the events at Life Esidimeni in Gauteng. The biggest risk centres on the 72 hour patients in casualty wards. It is important that no patient stays in casualty. A second challenge is that a patient’s documentation has to meet certain requirements, and more capacity is needed to prepare the documentation properly and timeously. All patients go through a review board, and sometimes the administration of this creates a bottleneck. A third challenge is safety - it is important that access to mental health facilities is restricted so that the patients are safe and protected, and can be prevented from absconding.  

Discussion
Dr W James (DA) said that he realised that dealing with psychiatric patients was often difficult and required highly specialised staff, but that it seemed that the province is being hampered by large bed shortages, staff shortages, and the pressure being put on rehab centres. Where is ECDoH going to find the extra resources required to finance all of this? How much money would be required? The difficulties being experienced cannot be overcome unless the staff and infrastructure challenges are met.  

He raised four specific questions: (1) What is the cost per bed in the province? (2) How does the cost per bed compare to the national cost per bed? (3) What is the norm for the number of functional beds per hospital; (4) How many clinical posts (for psychiatrist and specialised nurses) have been affected by the baseline budget?  

Ms C Ndaba (ANC) asked (1) How many psychiatric nurses are employed in the province? (2) When is ECDoH going to be able to start recruiting people to study occupational therapy? (3) If there are patients who abscond, does this point to a problem with security, or is it due to inefficiency or negligence? How does ECDoH hold itself accountable for these events? (4) Are three review boards of three members each across the province adequate?

Ms L James (DA) asked if there was a backlog in waiting time, as this can be a big problem for families. In the context of increasing substance abuse, what are ECDoH’s plans for outpatient rehab, especially for the youth? How should communities be educated so that people have a better understanding of the effects of substance abuse and to better access health care facilities? Are primary healthcare workers able to pick up on substance abuse at an early stage, which would help with prevention?

Dr P Maesela (ANC) asked if any effort was being put into finding out the root cause of substance abuse, and stressed how important it is to reach out to children through the schools at an early age. He questioned the meaning of “long term stay”, asking if it meant an indefinite period of time, in which case should this kind of care remain institutionalised or should these patients be moved to other facilities? Is there a current crisis with a shortage of occupational therapists? Why is the eastern side of the province being concentrated on?

Mr A Mahlalela (ANC) noted that a national framework for the improvement of mental health across the country had been agreed on almost four years ago. He asked about the progress made in implementing this in line with the Mental Health Care Act of 2002.  He was concerned about what seemed to be an absence of promoting the prevention of substance abuse, and why it seemed that intersectoral collaboration was not working (such as with the bursaries offered by DoE). The monitoring and evaluation of patients is critical, so how is the system in the Eastern Cape functioning to ensure this is being done regularly? He was concerned about the infrastructure challenges and asked what other plans were being put in place in the long term. There is an overlap with some patients, so is there a memorandum of understanding between ECDoH and the Department of Social Development?

Mr Mahlalela said that he would have preferred a report that was less abstract and based more clearly on the Mental Health Action Plan 2013-2020. The Mental Health Care Act provides for specific responsibilities for state patients and he asked ECDoH how these patients are being managed in accordance with those requirements. Does ECDoH believe it has the capabilities and the capacity to manage this function? This is in the context of the Health Ombuds Report where one of the recommendations was to review the Act and shift some provincial functions up to national level. How are the Eastern Cape review boards functioning in terms of being independent of political issues, and are they functioning adequately?

The Chairperson asked about the number of defaulting patients. He asked how traditional healers were being addressed. Some patients prefer to go to a traditional healer because they believe they have been bewitched, so how are the communities being advised about this. She felt that there was insufficient focus in advocacy on promotion and prevention, and asked what if any programme for community empowerment had been started, to enable people to realise the seriousness of mental health problems in the family.

Dr Dyantyi replied she is able to assure the Committee that the review boards work independently, although they have to report to the MEC quarterly, and the working relationship is good. The ECDoH does interact with traditional healers and they have a unit working with different types of healers, but some had started using mercury in their cures so there were occasionally potential problems.
 
Dr Dyantyi said that there are concerns about funding, because the shortage impacts adversely on the infrastructure. Even though the budget increases annually, it is still not enough to work through the backlog especially since they had inherited patients in the Transkei and the Ciskei and the western part of the province.  ECDoH works very closely with the Departments of Social Development and Education, but the focus is on occupational therapists because so many have moved out of the mental health care facilities that the impact has been strongly felt. Offering more bursaries is a long term strategy and, in the meantime, the DoH will concentrate on more recruitment. The agreement between DoH and DSD is that frail care patients fall under the care of the DSD, unless the patient also suffers from a mental health problem.

Dr Matiwane responded on how ECDoH works within the Mental Health Policy Framework (MHPF)and Strategic Plan 2013-2020. The National Health Act is their guiding principle, and defines how care is provided, patients are handled and procedures are implemented. Minimum safety standards are followed very closely. He would have to get back to the Committee about the cost of a hospital bed, but thought it would be in the region of R500 000.  The situation with human resources is reflective of historical factors.

He added that there is a large demand for services for long term patients, some of whom never go home. There is insufficient space and beds for acute mental health patients, especially with the increase in acute toxic psychosis. A heavy drinker going through withdrawal will come up as an acute mental health patient. These patients should not be left in casualty, and some of the district hospital beds should be made available. The strategy is that these beds should be converted to care for more mental health patients.

Infrastructure challenges are big: maintenance costs reach up to R1.4 billion per year, and there is insufficient money to build a new hospital. The focus is therefore on revitalisation and refurbishment of existing facilities.

Dr Patrick Maduna, ECDoH Deputy Director General: Clinical Management Services, apologised for any omissions inthe presentation. The ECDoH is trying to work closely with DSD in the area of accessing the youth to assist with the prevention of drug abuse. An example is the initiative at Malgas Centre, but other initiatives are lagging behind. The demand is bigger than anything ECDoH is able to do to combat the problem. Improvements are being made in trying to extend the teams to include a psychiatrist, a doctor and a nurse, to prioritise mental health care, as well as building up community networks to gain better access. The focus on the eastern side of the province is due to the services there being less comprehensive than those in the central and western areas. Monitoring and evaluation is regular and ongoing: our performance reports are compiled every three months to give feedback to our principals.

The Chairperson reflected that problems with mental health care are not uniquely South Africa. The lack of response from the MEC for Social Development in the Eastern Cape was not appreciated because it is very important to understand how the intersectoral relationship works. The Committee wants to conduct oversight on this, and will also require more information about the care of state patients in the Eastern Cape.

Western Cape Department of Health (WCGDoH): Health care services for mentally ill patients
The Western Cape delegation included Dr Nomafrench Mbombo, Western Cape MEC for Health; Ms Zimkhitha Mqutheni, Western Cape Ministry of Health spokesperson; Ms Tobeka Qukula, Director: Community Based Programmes; Dr Saadiq Kariem, Chief Director; Dr Douglas Newman-Valentine, Director Ministry of Health; Ms Siviwe Gwarube, Head of Heath Ministry, Dr Beth Engelbrecht, Head of Department.

Dr Nomafrench Mbombo (Western Cape MEC for Health) said she was glad that mental health is receiving greater focus than in the past. There is a lot of legislation around mental health patients which, although it demands greater responsibility, is also good. Mental health issues cover the spectrum from communities to primary health care and privately licensed NGOs. 

She said a review of the Mental Health Care Act would be welcome because concerns have been raised many times: there is often too much red tape and resources are severely taxed. Mental health and state patients have specific requirements, so sometimes there needs to be a different way of helping compared to “general health” patients. A medical solution is not always the only one when it comes to mental health, particularly when it comes to the de-institutionalising of patients, and legislative parameters have to be adhered to. There is also accountability, and how community-based carers are to be held to account.

Dr Beth Engelbrecht, Head of Department, presented the report WHICH concentrated on the governance of mental health services and statutory obligations, including licensing private and community-based mental health service entities, contracted community-based services, service delivery model and service strategy for mental health services.

Dr Engelbrecht said that their efforts were on trying to integrate mental health care into a whole care system as opposed to a vertical system. This involves connecting with communities and helping to eliminate the kind of stigma that is sometimes still attached to mental health problems. Recent developments at Paarl Acute Psychiatric Hospital and the Acute Psychiatric Unit at Mitchell’s Plain Hospital were to protect both patients and staff, and to make everything more patient-friendly. For some reason, there has been a surge of patients with acute psychotic illnesses in the last three months of every year, and in 2016 it was necessary to utilise some surgical beds. Mental health problems are part of a chronic condition, and the burden of helping patients is increasing.  

In conclusion, patients with acute psychotic illness crowd out patients with other illnesses, such as depression or anxiety disorder, and the WCGDoH recognises there are many unmet needs in the province. People also need to be empowered to know their rights, and intersectoral action needs to be embedded at district level. Funding and policies need to encompass a broader service transformation agenda.

Discussion
Ms Ndaba asked about licensed NGOs, and whether the good facilities she has seen in Khayelitsha exist in other disadvantaged areas. Why is the budget for contracted community-based residential care services higher in the Overberg district when other districts have more clients?

Dr James asked what the strategies were for retaining employees, and how do they ensure a supply pipeline for key professions. Is there a proactive strategy to match professionals with the needs of the province’s patients?

Ms James asked what, if any, was the nature of the working relationship between traditional healers and western medical practitioners. Are traditional healers invited to awareness days, and are they part of the community? Are nurses working at the primary health care level trained to pick up on patients who are substance abusers? And if so, where are those patients referred to for help? What is the nature of the relationship between the Health and Social Development departments?

Dr Maesela asked if all existing infrastructure had been modernised, or if Paarl and Mitchell’s Plain were just for demonstration purposes? He queried how independently the review boards ran, and also how mental health patients were informed of their rights. Is the appeal process reserved for mental health patients only, or for all patients? Had the WCGDoH ever been taken to court for negligence or any other issue? He was getting the sense that WCG Health never experiences any difficulties and that everyone knows how to do things correctly. How does the provincial strategy goal 2 (“to improve education outcomes and opportunities for youth development”) relate to school health in impoverished areas and informal settlements? Is provincial strategy goal 4 (“enable a resilient, sustainable, quality and inclusive living environment”) already being implemented? Unpleasant events do occur and should be highlighted, otherwise an unrealistic impression of reality is created. He would like to know how the WCGDoH is working with communities such as Khayelitsha and Saldanha, in terms of an equitable implementation of strategies. Adolescents need education about contraception and nutrition. The greatest driver of ill health is poverty, so our priorities need to be restructured so we can begin here. South Africa’s inequalities are the root of the problem.

The Chairperson said that she would like more information on the role of public mental health facilities, as most of the Western Cape’s facilities were private ones. How many mental health institutions are there, district by district? The presentation makes no mention of State President’s patients, or frail care patients, or defaulters. Do people in rural communities understand the 1 000-day perinatal period? How does your programme assist people in rural areas, where the stigma of mental illness is a big challenge? The delegation is invited to answer these questions in writing after the meeting, if necessary.

The Chairperson left the meeting and Mr Mahlalela took over as Acting Chairperson.

Dr Mbombo informed the Committee that the section of the presentation about licensed community organisations refers to applications from individual community members who want to offer a home-care service; it is not a case of the DoH tasking them to do so. In terms of the Mental Health Care Act, if more than five beds are offered, they do not fall within the Department’s jurisdiction.  It is the contracted community-based facilities that serve as an extension of the Department’s services, for example, a step-down facility.  Patients have to pay for private facilities. Both kinds of facilities have been included in the report because the Department has a responsibility to check on the quality of services regularly to ensure that the requirements of the Mental Health Care Act are being met. Some of our services consist of specialised high-care, and we have to look at the situation more broadly, from the community base to the tertiary level.

She replied to the questions from the Committee about human resources, noting that areas of specialisation had been identified (for example, advanced mental illness) for nurses. There is also engagement with the two medical schools in the Western Cape. The issue of working with mental health patients being taxing on staff is a real one, and a programme called Care for the Carers has been initiated. One of the problems with traditional healers is that the National Health Act requires health care providers to be accredited by a recognised medical council, so they fall outside the Act. Greater intersectoral collaboration is required. Engagement at the primary health care level does exist.
 
She added that, in the South African context, substance abuse is viewed as a psychosocial response to problems, requiring lesser assistance from the Health Department and more from the Department of Social Development. The WCGDoH has a working relationship with that department, as well as other departments like Sport and Arts & Culture.

Part of the WCGDoH’s planning for improvements in infrastructure includes adding some psychiatric units in certain district hospitals. Khayelitsha has already been identified as needing a psychiatric unit, and extensions are planned for Victoria and Heideveld Hospitals. As far as possible, it is preferable for mental health patients to be de-institutionalised, although not to the extent of isolating them. The provincial MEC has responsibility for the review boards in the province. Legal problems come across at the national level and the Western Cape is not free from being sued, although not so much over mental health issues. The report has included both private sector and public facilities, because if the provision of health care exists then it all counts. There is an annual inspection of the licensed mental health care providers, whether the WCGDoH is providing the services directly or not. Some contracted NGOs, like William Slater, also cater for physical health issues, for example, when a person is not well enough to return home but requires intermediate care. In connection with defaulters, the medical staff at specialised hospitals ensure that the continuum of care continues after the patient has left the facility.  

Dr Engelbrecht said that the presentation was intended to show how the WCGDoH governs licensing and monitors the process from application to regular review. There are districts where a service is put out on tender, and people are invited to apply.

Ms Siviwe Gwarube, Head of Western Cape Heath Ministry, added that they differentiate between intellectual disabilities and psychiatric illnesses. Patient might be in a club or a group home – it depends on the kind of service available in that particular district. Some are in a 24-hour care centre, so the funding would be higher than in a group home. A working relationship with traditional healers in various communities does exist, and healers are met with on a quarterly basis.

Dr Saadiq Kariem, Chief Director: Regional Hospitals, said that there are about 750 State President patients across the four psychiatric hospitals in the province, and those four provide approximately 2 000 beds. The number of private beds is 351. The most dedicated hospitals are Valkenberg and Lentegeur, but they are not the only facilities where mental health patients are seen. The example of the Acute Psychiatric Hospital in Paarl serves to demonstrate what they would like to achieve, but obviously these facilities do not exist throughout the province. The Mental Health Care Act was not very clear about certain requirements when it came to hospital planning, and we have prioritised some of the requirements. It was not the intention to suggest that everything always happens correctly or perfectly, but rather that there is an attempt to examine what is not being managed well and go back and deal with it.

The provincial strategic goal (“to increase wellness, safety and tackle social ills”) is the WCGDoH’s direct drive, and it involves a meticulous process of implementation. This is where the perinatal health programme comes in, and it also deals with issues about nutrition, reproductive health, and contraception.  Not every mother can be reached, but it is the intention. Mentally ill users, whether assisted or involuntary patients, are informed about their rights via their family or the people who applied to get them admitted to the facility. Assisted voluntary users are definitely able to understand their rights. Sometimes it is too restrictive and isolating to take a person out of the community, which is where community-based care can be so effective.
The mental health review boards are only for mental health patients.

Dr Mbombo added that the WCGDoH does not fund the NGOs or private facilities if a patient has been pre-diagnosed. Certification must be properly authorised in advance.  

Ms Jeanette Hunter said that it is crucial to build strong community-based health services across the country, and this is better able to happen at the provincial than the national level.

The Acting Chairperson said he was very pleased to see the kind of work that the province is doing in the mental health care sector. The Lentegeur Psychiatric Unit at Mitchell’s Plain in particular shows that people in very poor areas are being helped, and the right interventions are being made.

The meeting was adjourned.