Health Care Services for the Mentally Ill: North West DoH; Public Hospitals audit: OHSC Briefing

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Health

15 March 2017
Chairperson: Ms S Dunjwa (ANC)
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Meeting Summary

The North West Provincial Department of Health reported to the Committee on the state of health care services for mentally ill patients in the light of recent events at Life Esidimeni in Gauteng. The report looked at the number of beds available versus the needs of the patients, the type of facilities and resources available, human resources, the independence of review boards and service strategies.

The Committee had many questions for the provincial department including how it was addressing he lack of licensed NGOs, how it coped with service delivery if only 11 sub districts had mental health care coordinators, appointment of more mental health coordinators and reasons for the high mortality rate. Members were concerned about the budgetary constraints and under spending, filling of vacancies (which compromised the provision of health care) and waiting lists for mental observations. There was further discussion on the minimum level of training to those working in primary health care, district and specialist teams, Mental Health Review Board and addressing misconceptions about mental health. The Committee sought more information on the state of infrastructure of facilities, if they were adequately staffed and their security status. Elaboration was also requested on strategies for promotion and prevention, intersectoral collaboration, how mental health systems were monitored and evaluated and which districts in the North Wets province were most hard hit with mentally ill patients.

The Office of Health Standards Compliance then presented its 2015/16 audit findings of public hospitals. The presentation covered national core standards that were applied to the inspection of any medical facility, namely, patient rights, safety and clinical risk and clinic support services. Questions were asked by Members about how the OHSC was able to regulate compliance with requirements and what measures were in place to deal with facilities/staff where there were problems.

The Committee questioned systems of monitoring, findings on waiting periods for patients and management of strategic compliance – Members were interested in knowing whether the OHSC had power to insist on compliance and if there were penalties for non-compliance. Members also questioned whether the OHSC was satisfied with security measures at public facilities, budgetary constraints and the attitude of communities towards health workers.  

Meeting report

Mental Health Care Services in the North West Province

Dr Magome Masike, MEC: Health, North West Provincial Department of Health, led the presentation which covered facilities available in the four districts of the province, number of mental health beds in specialised hospitals, designated psychiatric units attached to general hospitals and private hospitals licensed to render in-patient services. The presentation also looked at units for 72-hour assessment in general hospitals, primary health care services, community mental health services, co-ordination of services and the Mental Health Review Board. Members were then informed of the number of deaths annually, staff establishment, budget and expenditure trends and key challenges.

The presentation highlighted that were two specialised hospitals (Witrand and Bophelong), two designated hospitals (Taung District Hospital and Job Shimankane Tabane Provincial Hospital) and two 72-hour assessment units (Tshepong and Mafikeng). The provincial department also had three licensed private hospitals that provided mental health services (Multicare, Parkmed and Kgatelopele Wellness Centre). No NGOs were licensed to provide mental health services. The services offered at Witrand and Bophelong included general psychiatry, physical medicine and rehabilitation, intellectual disability, forensic observation, prisoners’ services and adult, child and adolescent Out Patient Department (OPD). There were 12 district hospitals, 49 community health centres and 270 fixed clinics.

Planned community residential beds across the province numbered 464. There were currently two vacant posts at Assistant Director level - staff in these posts would be responsible for the administration of the Mental Health Review Board. It had also not been possible to appoint a Directorate for Mental Health, headed by a Director, due to budgetary constraints.

MEC Masike outlined the Mental Health Review Board in the province was set up in 2007 and comprised of four members - one legal, two Mental Health Clinic (MHC) practitioners and one community member. The current contract expired 31 March 2017 and new board members will start on 1 April 2017. The Board met weekly and catered for all four districts. Its functions were to screen all documentation relating to mental health patients from the four hospitals, to conduct support visits to hospitals to check compliance and to conduct in-service training.

The causes of deaths in the last five years at Witrand and Bophelong were generally due to medical conditions such as pneumonia. Monthly morbidity and mortality meetings took place, where all cases were discussed. Corrective measures were taken where applicable.

Key challenges included the inability to recruit and/or retain specialised staff, inadequate funding and infrastructure challenges. It would also be ideal to have a mental health co-ordinator per sub-district to champion the preventive and promotive aspects of mental health care as currently only 11 of the 19 sub-districts had appointed mental health co-ordinators.

Discussion

Mr W Maphanga (ANC) asked whether anything had been done to address the lack of licensed NGOs since they play an important role in local communities. How did the provincial department cope with service delivery if only 11 sub-districts had mental health co-ordinators? Was it possible that the current budgetary constraints will be lifted in the future? And what were the reasons for the high rate of mortality?

Mr T Khoza (ANC) remarked that the North West Department of Health had presented a good report but it didn’t mention many challenges. He asked what the minimum level of training was given to those working in primary health care because those people needed to be trained properly. What were the challenges preventing the filling of vacancies?

Dr W James (DA) commented on the large number of vacancies and asked what efforts were being made to fill the empty posts. Vacant posts would mean that patient care was being compromised.  

Dr P Maesela (ANC) asked why some patients were still resident in mental health facilities after more than 20 years. When will the mental health co-ordinators be appointed? Who appointed the members of the Mental Health Review Board? And who did the Board report to? Did district specialist teams exist and, if not, why not? What was the state of the infrastructure of the facilities? Were they adequately staffed? What was the security status of these facilities? Were they properly secured and safe enough for mentally ill patients? 

Mr A Mahlalela (ANC) asked how the North West provincial Department of Health reconciled the cited budgetary constraints with the failure to fill all vacancies.  He felt that more clarity on the apparent under spending at Bophelong Hospital was needed. He then queried the staff establishment figures. How was the Department dealing with the requirements of the National Mental Health Policy framework? He would have liked more information about the strategies for promotion and prevention. If research had been done to understand the main causes of mental health problems in the province, what progress had been made in developing a plan based on the findings?  He would also have expected more information about intersectoral collaboration and how the mental health system was monitored and evaluated.

Ms L James (DA) asked if there was a waiting list for mental observations and, if so, how that was dealt with. Why was the number of approved beds for chronic psychiatric patients at Witrand Hospital zero? Was it because there were no chronic psychiatric patients or was because they had no beds? She also noted that the most important thing should be promotion and prevention at the primary health care level - people needed to be educated and made aware of problems. Some people still thought mental problems were caused by witches – how was the Department addressing this?

Were the staff at the clinics trained and equipped to diagnose substance abusers? Was a holistic assessment required to understand the underlying issues? This should also apply to the primary health care level. How was the North West provincial Department of Health going to fill the vacant posts and improve the situation?  She would also have liked more detail on the nature of the infrastructure challenges that the Department was experiencing.

Ms D Senokoanyane (ANC) also asked about the reasons for so many vacant posts. She thought it was imperative to have health promoters in all the districts, not just health co-ordinators. What was the nature of the 72-hour assessment at the general hospitals? What was happening at the private hospitals, particularly in terms of challenges?

The Chairperson said that the presentation did not assist the Committee to “feel” the actual state of affairs as far as mental health was concerned despite the Committee having been very clear about what the report should focus on. What had the North West provincial Department of Health observed as far as traditional healers were concerned, and different religions, affecting those who were mentally ill? Were community-based home care workers empowered to notice and deal with symptoms of mental illness? Did home care workers have a good understanding of what was required in terms of compliance with the National Mental Health Act?  

She then questioned the reasons that caused death with mentally ill patients – apart from the mental condition, were there other illnesses, such as diabetes or TB? In the province, which district was the most hard-hit with mentally ill patients?  Why were some patients categorised as “acute” and what did this mean?

MEC Makise referred to the Committee’s original letter of invitation and said that if it had been more informative about its requirements, the North West provincial Department of Health would have been able to prepare a better report. In the last financial year, the Department’s budget increased by only 1.2% - next year will see an increase of 5%. “Budget constraints” meant exactly that - a R200 million overdraft currently existed and was co-managed by the North West provincial treasury.  Although posts in the area of mental health were prioritised it was hard to attract good professionals because of the rural nature of the province, so the challenges were not due only to budget constraints. The Department was also restructuring and reprioritising all its posts and putting in place measures to enhance the positions to make it more attractive to applicants. An example of this was the building of accommodation facilities at new hospitals.  

In the absence of mental health co-ordinators in some of the sub-districts, the professional nurses were also given in-service training by the province on how to handle mentally ill patients. This was one means of dealing with mental health issues at the primary health care level.  The Department also employed community workers to go house to house to follow up on patients who were on medication. Patients who defaulted got referred to facilities. Health education was provided at household level and at ward level. Mental health issues were incorporated into other programmes so there was a lot of integration.  

MEC Makise outlined the 72-hour assessment period would be good to have in all district hospitals. When a patient presented, he or she was taken to a designated hospital. The meaning of “acute” in this context meant that the patient can be admitted and treated for a period of six weeks or less. After that the patient would be referred to one of the main provincial psychiatric hospitals. “Acute state patients” were those patients who had to stand trial but had to undergo psychiatric observation first. If the patient was certified as mentally ill, they become chronic.

Dr B Mothusi, Director: Health Programmes, North West provincial Department of Health, said that the new Bophelong Hospital will have 60 beds available for patients who required forensic observation - this will help with the backlog. On occasion some of the patients were referred to Weskoppies for further treatment. As far as training was concerned, the Department had been receiving a number of applications from outside the province. 321 nurses graduated recently in psychiatry training – of these, 274 were from colleges in the North West and 47 were from the university in the province.  

He confirmed that the promotion of good health was an important aspect of the North West provincial Department of Health services and a directorate for mental health would mean that the services could be better co-ordinated. The Department had very healthy relationships with the SA Police Service, Department of Justice and Department of Social Development. There was regular collaboration and discussion.

Another member of the delegation added that, if a patient presented suicidal tendencies or severe depression or violent behaviour, he/she first needed to be stabilised and only then can it be seen if the condition was chronic or not. The admission criteria in the province were very profound and if a patient was very sick or spastic, he/she will be referred to Witrand.

There were 35 vacant posts for professional nurses and they can only be filled when the resources were available. In connection with substance abuse, Witrand had a facility to deal with this inside the hospital but not separately. There was a memorandum of agreement with the Department of Social Development (DSD) that users be admitted. Medical conditions can be excluded once the cause of the problem was known to be due to drug abuse. The DSD built its own drug and substance abuse unit. The province conducted outreach services to all healthcare facilities but the psychiatrists, psychologists and social workers were moving out.

Dr Mothusi said that intersectoral collaboration existed with traditional healers and other practitioners.  The Mental Health Review Board was appointed by the MEC. Interviews for a new Board were completed last year and everything was in compliance with the Mental Health Act. The Review Board functioned very well and members of the North West provincial Department of Health occasionally attended its meetings. The reports of the meetings were sent to the MEC and the Review Board visited all institutions.

The security in psychiatric hospitals was not at an optimum level. CCTV was installed and when a patient was secluded there was a monitoring tool, the monitor is always on. A process of constructing better fencing had begun but it was very expensive so the process had to be completed in phases. The entrances of the facilities had security staff in attendance and people entering were searched.

MEC Makise said that infrastructure challenges definitely existed. The North West provincial Department of Health had collaborated with National Treasury and managed to complete Phase 2a of state patient wards. Including a forensic investigation unit, this will cost upwards of R596 million. Another project was the staff accommodation at Bophelong - Phase 3 at Bophelong will be advertised shortly and this will include an admin block and other facilities. There had been some challenges with service providers and the provincial Department intervened where it can and collaborated with other stakeholders. The staff accommodation being built was state of the art and was one aspect of the retention strategy - better roads and schools were also needed as part of a broader developmental issue to keep skilled people in certain areas.

The North West provincial Department of Health had licensed private hospitals to provide mental health services and, although more statistics needed to be collected, the hospitals were inspected annually to ensure compliance with the National Health Act and the Mental Health Care Act.  

Expenditure figures shown in the presentation related to the end of the third quarter. Expenditure was closely monitored and it was hoped that by the end of the fourth quarter the situation with Bophelong would have improved and that there was no unauthorised expenditure at Witrand.  In reality, it was very difficult to make the current budget work well and sufficiently so as to be able to fill the vacant posts. The provincial treasury was approached for funding to enable some critical posts to be filled just before end of the third quarter but the request was declined. The National Department of Health was also asked for assistance. A new model had now been agreed on to motivate to fill these posts. The North West provincial Department of Health staff budget for the new financial year had only grown by R400 million so similar problems will be experienced in the future.

A detailed record of causes of death of all deceased patients was available and would be sent to the Committee.

The Chairperson said that, if the North West provincial Department of Health was aware that mental health services were provided in line with the national policy framework, the presentation should have touched on that. If anything in the invitation of the Committee was unclear, the Department could ask for further instructions so it the exercise did come across as an ambush. She asked the delegation to provide information about which district was hardest hit by mental disorders and what the factors involved were.  

Office of Health Standards Compliance (OHSC): National Core Standards Inspectorate Annual Report 2015/16

The Chairperson said that it was unhelpful that the OHSC had not managed to send copies of their report to the Committee in advance of the meeting.

Dr Mahlalela agreed saying it was unfair.

Mr Bafana Msibi, Acting CEO, OHSC, apologised on behalf of the Board for not having made the documents available well in advance of the meeting. He said that there had been challenges from the office and from the supplier and it could not be emailed because it was too big. They were obliged to send it by courier, which was why it only arrived on the morning of the meeting.

The Chairperson accepted the apology.  

Prof Lizo Mazwai, OHSC Board Chairperson, noted that the report represented the 2015/16 financial year and that it would be preferable to present a report within six months of the end of the financial year.  

Mr Msibi took the Committee through the presentation which gave the context of the organisational structure and service model of the OHSC, evolution of the process of policy reform, legislation, national domain outcomes, key challenges and general findings.

Discussion

Dr James remarked that the best system of monitoring was for it to be done independently without any political influence. He thought the system would be better if the Minister was not involved in the appointment of OHSC members.  If the most important problems related to poor leadership and corporate governance at clinics, how was strategic compliance managed? Did the OHSC have the power to insist on compliance?

Mr Khosa commented on the effects of poor management which could flow down to issues about cleanliness. He asked what the Board’s findings were with regard to waiting periods for patients – were people being sent home to have to return later? Was the Board satisfied with the security measures in public facilities?

Dr Maesela thought that hospital staff can surely be managed better in order to comply with basic levels of cleanliness. Budgetary constraints were a common problem - did the constraints arise as a result of part of the budget being used for something that was not originally planned?

Ms James said that waiting times had always been a problem in community health centres. How were the facilities being advised to manage this better? How was the management of the facilities being advised to improve issues so that changes will be seen in the future? Were there any penalties imposed when facilities/leadership were not complying?  

The Chairperson noted that the inspection that the report was based on was already a year old thus questions of the Committee may have already been resolved or was an issue being improved.

Prof Mazwai replied that certain processes took time - after the OHSC’s inspection and the compilation of the draft report, it had to go back to the CEO and the provincial HoD in case there were any problems which then have to be followed up before going to the Minister. He thought that perhaps at that stage the Chairperson of the Portfolio Committee should also receive a copy.

There had been a delay in getting some of the regulations. Within the Act there was provision for action in terms of imposing penalties but no penalties had yet been implemented because if it was a management problem, it got referred to the HoD. Those areas had to be highlighted and action on them was requested. If the response was poor, recommendations were made and then the facility was re-inspected.

Mr Msibi said that the OHSC provided feedback to the provincial executive management and the MEC was also involved in that. There was definitely commitment from leadership in that respect. The issue of waiting times for patients related to the length of time a patient had to wait for a procedure to be performed, the amount of time a patient had to wait after arriving at a clinic or hospital and until he/she could leave. The time involved included the patient collecting his/her file, going to the pharmacy, etc.

Recommendations could be made about how to improve systems and issues within provincial facilities but the OHSC was not prescriptive because what worked in one hospital might not work in another. One of the problems that had been identified was a lack of guiding strategy in terms of standardisation.

Ms Audrey Montshiwa, OHSC member, said that, with the NGO sector, in the new pilot sites, medication was sent directly to the patients’ houses or they collected from the pharmacy. The NGOs could also arrange pick-up points which meant that patients could be monitored at the same time. This was to address the problem of long queues at clinics and brought down waiting times. The clinics were complaining a lot less these days because patients were going via NGOs or pick-up points. Tshwane was a pilot site for a new system where ‘fast lanes’ for certain patients will be made available (e.g. children, elderly people).

Prof Ethelwynn Stellenberg, OHSC member, said one of the critical things that needed to happen was an improvement in the quality of programmes. This was already happing in Mpumalanga. The biggest problem was attitude, not only at the operational level. For instance, there was an oxygen leak in one of the hospital theatres and the consequence could have been a terrible fire. Good attitudes would prevent a lot of problems. Research had shown that budgets not used well would definitely affect patient care adversely. The Marathon Project in Gauteng, under which mentally ill patients were transferred from Life Esidimeni in 2016, had caused terrible problems. Primary Health Care practitioners should be going out with the mobile clinics because some nurses were not able to understand how to conduct a proper physical examination and refer patients to appropriate facilities.

Ms Jeanette Hunter, Deputy DG: Primary Health Care, Department of Health, said that, in her opinion, the OHSC’s report was very good and displayed the reasons why government wanted this body in the first place. The report must be taken very seriously but the Department could not be reactive. There were key indicators that were monitored by hospital service directorates so the need was to be proactive and ensure that management of the facilities complied with requirements and standards. Resources and leadership were key components to success. District hospitals in particular showed poor performance. Even where a facility could show that the clinical care was good and there was sufficient staff, the need for quality management intervention still existed because, without good governance and leadership, everything would collapse. 

The Chairperson asked about the attitude of people in communities towards health workers. Sometimes in public institutions, people looked down on health workers and some were even being assaulted. When the Committee conducted its oversight, it would need to know which facilities had already been inspected by the OHSC. It was good to hear that there were objective views about, say, pilot sites, and that positive changes could be observed.  

The meeting was adjourned. 

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