Social determinants that apply pressure to the health system & mental health challenges: Department of Health & Department of Social Development Briefing

Health and Wellness (WCPP)

23 September 2022
Chairperson: Ms W Philander (DA)
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Meeting Summary


The Standing Committee on Health in the Western Cape Provincial Parliament convened in a hybrid meeting for a briefing by the Department of Health and the Department of Social Development on the programmes in place to address the social determinants that apply pressure to the health system, specifically in Khayelitsha and Mitchells Plain Hospitals.

Provincial Minister, Dr Nomafrench Mbombo, made brief opening remarks thanking the Committee for raising such a pertinent issue on mental health challenges in the province. She said the situation had become particularly challenging since the COVID-19 pandemic, which had a major impact on individual and community mental health.

The Minister told the Committee that there are advanced psychiatric nurses, but the question remained on the mental health status of a community on its own and how this could be dealt with effectively. The Committee heard that, during load shedding, almost R250 000 was spent on diesel for generators over two weeks at some hospitals in the metropolitan.

The Department of Health reported that from 01 January 2019 to 31 December 2021, the Forensic Pathology Services recorded 2 188 deaths due to suicide in the Western Cape. The peak number of deaths each year occurs in December. There was a marked drop in suicides in April 2020, at the time of the lockdown. Despite that, there has been an upward trajectory since April 2020 to date.

The Department also raised that R500 million in funds was needed to ensure facilities have the capacity to service patients effectively. Minister Mbombo assured the Committee that resources were shifted to provide funding for mental health, COVID-19 and the HIV/AIDS grant. She highlighted that Community Psychiatrists have also been appointed to do outreach work in mental services to broaden the focus from those patients who have already been institutionalised. She emphasised that the Western Cape had made mental health a priority in addition to jobs to ensure it becomes transversal. She stressed that Departments should refrain from working in silos.

The Department of Social Development reported that there is also an in-treatment centre at the Department of Social Development, and here and there, 30 female adults are accommodated. A facility for males is being built. There are in-house Child and Youth Care Centres, various awareness programmes for substance abuse and a youth facility that can accommodate fifty children.

Members raised several issues on the interventions and services available on a primary healthcare level. They asked whether the resource funding gap of R500 million had been addressed with National Treasury, and how the shortage of beds and staff in psychiatric hospitals would be addressed. Members also asked whether there was a need for more rehabilitation centres in Khayelitsha, Mitchells Plain and other working class communities.

Members asked how substance abuse was being addressed. They expressed concern about suicide rates and the revolving door syndrome of patients, which places further strain on already under-resourced facilities. The Committee sought clarity on the role that the South African Police Services play in admitting mental health patients to facilities.

There was concern about the stigma attached to the word ‘abuse’ in ‘substance abuse’, and the Committee was asked to amend this in legislation to prevent individuals from not seeking help when they need to. Members asked about the number of funded non-profit organisations the Departments worked with, and whether rural communities had access to services related to mental health issues. How do the Departments market their services to communities? Members emphasised the importance of the mental health status and wellness of staff who need to attend to patients.

The Committee then considered and adopted its draft reports and minutes from June to August 2022, without amendment. In her closing remarks, the Chairperson emphasised that addressing mental health challenges requires an integrated, holistic approach of many Departments and stakeholders.

Meeting report

The Chairperson opened the hybrid meeting, welcoming everyone present. She asked Members on the virtual platform and physical venue to introduce themselves. She also welcomed the Western Cape Departments of Health and Social Development. The guest delegates present in the meeting also introduced themselves.

The Western Cape Provincial Minister of Health, Dr Nomafrench Mbombo, made brief opening remarks. She thanked the Committee for raising such an important issue on mental health, particularly since the COVID-19 pandemic, which has impacted the mental health of individuals and the community mental health status. She also introduced all the guest delegates.        

The Chairperson said that the Department of Health would give a briefing on its mental health programme, having observed the severity of mental health challenges in various hospitals across the province and mental health challenges at the district level – specifically in places such as Mitchells Plain, Khayelitsha, amongst others. The Committee resolved that mental health in the province needs urgent attention. The Department of Social Development would also present social determinants that apply pressure to the health system, specifically in the Khayelitsha and Mitchells Plain District Hospitals.

The Chairperson handed over to the Department of Health.

Briefing by the Provincial Department of Health: Mental Health

Ms Carol Dean, Specialised Hospitals Director, made the presentation to the Committee.

The Western Cape Burden of Disease Report found that, in terms of suicides, there has been a worrying trajectory, following an increase since April 2020. About 90% of people who commit suicide have an underlying psychiatric illness. Between 2010 and 2016, suicides were 11% of all injury deaths (1.5% of all deaths) nationally. Suicides were three to four times greater in males, who had more attempts by females. The Western Cape had the highest 12-month and lifetime prevalence of mental illness in SA (39%). Anxiety disorders were 19%, mood disorders 14%, and substance use disorders were 21%. Less than one in four people with mental illness seek care.

From 01 January 2019 to 31 December 2021, the Forensic Pathology Services recorded 2 188 deaths due to suicide in the Western Cape. The peak number of deaths each year occurs in December. There was a marked drop in suicides in April 2020, at the time of the lockdown. Despite that, there has been an upward trajectory since April 2020 to date.

The COVID-19 pandemic has had an impact, along with upstream factors related to socio-economic factors, poverty, and unemployment – strong drivers. The provincial Department also requires support from its WOGA (Whole of Government Approach) and WOSA (Whole of Society Approach) partners. There is also a significant funding gap. The Department Head acknowledged that R500m is required, and mental health needs prioritisation – even in terms of human resources and infrastructure. The additional funding will help strengthen the Child and Adolescent MH services, psychogeriatrics, and acute services at the George and Paarl Hospitals.

The Mental Health Steering Committee for Mental Health, chaired by the HOD of Health, convened with technical support from DOTP and the other WCG Departments, to confirm a WOSA roadmap for the medium-term expenditure framework - a three pronged approach – data-led, evidence-informed and focus on geographic areas. Focus was mostly put on youth. There are two pilot sites, Klipfontein and Witzenberg, where mental health mapping would be done with key partners, DOE, DSD, DCAS, etc. The aim is to promote the implementation of WOGA and WOSA.

[See presentation for more details]


The Chairperson asked about the interventions and services available on a primary healthcare level. She said that Ms Dean mentioned an unmet need where one in four cases seeks assistance. She asked how this determination was made. The Department may be ready to handle these cases, but the system is still strained. So, how, using a holistic approach, will the Department reach out to the community that it is unaware needs assistance?

Ms R Windvogel (ANC) said that the presentation was an honest reflection of the situation, but was a bit scant on details of proposed solutions. The presentation named a number of serious factors such as a funding gap and the need for R500 million that would be used for human resources and infrastructure. Given the impact of the COVID-19 pandemic on mental health, she asked what plans were in place to address the gap in the shortage of resources. Has the R500 million issue been raised with the National Treasury? What is the breakdown of this amount, and how much of it will be made available in the upcoming budget adjustment?

She noted that Alexander was not on the list, but Ms Dean covered this in her presentation. She said the elephant in the room needed to be addressed –the shortage of beds and staff members in psychiatric hospitals. She asked if the 1 827 beds across all four psychiatric hospitals were enough. If not, are there plans to increase this number? Does this mean that there is equity in mental healthcare? What are the relevant details, and how will this be addressed? ‘What is the prevalence of mental health in rural regions, and what percentage of mental health resources is allocated to rural regions?

On slide 11, mental health is said to be a funded mandate for district hospitals. However, if one looks at the KDH management, it is clear that mental health patients are a contributing factor to the service pressure that has caused patients to sleep on floors. Part of this is the referrals to Lentegeur Hospital. According to her knowledge, there is space at the Hospital, but no funding is available. She asked if there were additional staff members to deal with mental health patients at KDH, and if there was any additional budget available to adjust the budget for KDH. What is the Department’s view on KDH being made a regional hospital? Would this help address some of the challenges?

Minister Mbombo said that she wanted to give the Committee some perspective. The staff was in the same position of thinking of where the money would come from. For them, it was also about how Members, as influencers in the legislature, could mobilise resources on their behalf. What has been presented is not only about mental health, but they are painting a bad picture of what is happening in the communities. As the Committee alluded to, there are also issues relating to beds. R30 million in her budget speech was allocated to adolescents and psycho-geriatrics. Adolescents are staying with their parents, and they also have substance abuse issues. What can be done to prevent this and ensure that twelve-or fourteen-year-olds are not admitted for observation? How can you contribute to that?

The current figures are higher than those shown prior to the COVID-19 pandemic. The Department should not only be talking about how we can mop this floor through resources, staff and beds, but also speak about how to close the gap. The point is that many people need help. A one-on-one conversation must be had between an individual and a Clinical Psychologist or a Social Worker. There is no space for this, because the only time they get to see an individual is when the house has already bolted. There are advanced psych nurses, but the question is the mental health status of a community on its own. How do we work around this aspect? For example, with load shedding and the funds needed for services, they have to ensure that they pump diesel into all those generators. Exemption is only extended to the city's Tygerberg, Red Cross and Groote Schuur Hospitals. All other facilities need funds.

On shifting resources and funding for mental health, a portion of this was added for COVID-19 and the HIV/AIDS grant. Community psychiatrists have also been appointed to do outreach work in mental services, so that there is not only a focus on acute or those patients who have already been institutionalised. The Western Cape has made mental health a priority in addition to jobs to ensure it becomes transversal. As has been evident, the Department is piloting this to ensure that all parties are under the same roof; they should not work in silos. She said that they would never be able to get R500 million anywhere. The equitable share of the Western Cape and Gauteng will be reduced, but she said that the Departments need to ensure that it tackles the socio-economic determinants of health, which cannot be tackled outside the government system, but rather by working with governments.

Minister Mbombo said that she had engaged National Treasury on the amount of money spent on diesel. There will also be engagement on this at the next MTEC.

The Chairperson excused Minister Mbombo from the meeting.

Ms Dean said that the Minister covered things quite comprehensively.

Ms Dean said that the number of one in four came from the SASH Study, which was done quite a while ago. This is where someone has done a few sessions but is not strong enough to come to the facility. She assured Members that there was help for this.

Ms Windvogel said that some of her questions were not answered. She asked about the R500 million and space available at Lentegeur Hospital.

Ms Dean asked if she could refer the question on the R500 million to Dr Cloete. She would follow up on this.

She said they are doing an audit of what wards are available right now and how they could utilise them differently. So, they are looking at a comprehensive service plan, as the Minister said. Acute beds are different, but the Department is looking at trying to get people into transitional care so they can get well and be discharged. The length of stay at Khayelitsha has already seen a huge improvement where patients were previously staying for 22 days. The patients are now only staying for 14 days. Funding is the one thing holding the hospital back, even when there is a vacant ward.

Ms Windvogel said that this did not really answer her question, as the agreement was stopped by Lentegeur Hospital, because the hospital could not afford it anymore. The patient was then transferred back to KDH. There is open space like the wards, and there is an agreement with an NGO. This is what she was referring to.

Dr Keith Cloete, Head of the Western Cape Department of Health, said an audit was being done on what was vacant at Lentegeur Hospital. There was a problem with a storm a while back, and Alexander had to move all their patients over to Lentegeur. She noted the question on Lentegeur’s budget, but would have to defer this question to the HOD.

Ms N Bakubaku-Vos (ANC) said that she knew the province had the highest lifetime prevalence of mental health illness in South Africa. Substance abuse also contributes to this. This emphasises the need for an effective approach from government over society. She asked the Department to outline the provincial government plans to address this concern. How much has been budgeted for this? What is government’s intervention? How many deaths have been recorded for 2022 to date?

On slides 18 to 19, on mental health presentation for emergency centres due to substance abuse, it is shown that the challenges are not only health-related, and other government departments need to become involved. Ms Bakubaku-Vos asked what partnerships exist between the various government departments. Is there a need for more rehabilitation centres in Khayelitsha, Mitchells Plain and other working class communities? What is happening in Khayelitsha, which has caused such a high increase in mental health presentation? To what extent has this contributed the increased service pressure at KDH? Slide 18-19 clearly indicates that additional mental units across these facilities are needed. How many mental facilities are there across the mentioned hospitals? What plans are in place to build them? What challenges are experienced in these hospitals? What are the current challenges for examination and in getting additional beds?

Ms Dean said that 39% was a high prevalence of mental health for the Western Cape. She could not provide a figure for rural areas, but would follow up on this. She was pleased that the Departmental colleagues of Social Development were the custodians of the Prevention of and Treatment for Substance Abuse Act. This does not mean that the Health Department does not have a role to play. There is a directory of facilities, which are close by. The Department is in the process of discussing substances, and it has a new master plan that has come from the national Department.

On what is happening in Khayelitsha, she said they need collective wisdom to understand social determinants. She would imagine this was caused by joblessness, environment, frustration and the youth. She would get back to the Committee on the backlog. New hospitals are coming on board, and infrastructure plans are in place for the Belhar Regional Hospital, Klipfontein, New Somerset, Khayelitsha and Lentegeur Hospitals. Hospitals are trying their best with the available space where there is no plan in place.

Mr C Fry (DA) asked about the revolving door syndrome prevalent in hospitals, where patients are treated and discharged but then relapse and return to the hospital. He understood the work of the Community Health Worker, but was sure the caseloads were overwhelming for them. What is the strategy for dealing with the revolving door syndrome? He then asked about the turnover of staff. How can the high turnover in psychiatric hospitals be prevented?

On the budget across the three psychiatric hospitals, he asked if the budget was the same across the three hospitals, and whether there was some form of clarity that it is not a case of robbing Peter to give to Paul – overly taxing one hospital to help another. When the police arrest someone with a substance, assume the person has a psychiatric condition and then immediately hand the person over to a psychiatric hospital, there must surely be a sense that the police cannot do this, given that they are not qualified mental health practitioners. What is the discussion with police on this in the specific catchment areas of the hospital?

Ms Dean responded that there was a process relating to the work of the Community Health Worker. There is a system to capture data for the mental health system, and they can now track the revolving door patient per area. She could not really comment on the turnover of staff, but there were long-staying staff and key posts at Lentegeur Hospital that were vacant. There has been a turnover of psychiatrists in Khayelitsha, but the Department has engaged in talks with clinicians to figure out how it can do things differently to have a system. They have had conversations about this, and it has been very fruitful. Organograms are also similar. They are looking at nursing ratios, and experience versus numbers categories. The Department as a whole has started talking about more equity-resourced allocations. She found that the police have been very cautious in arresting someone if there has been a suspicion of mental illness, as they know this could be a civil case. If they bring a patient to hospital, they have to hand over Form 22, which states the physical condition of the person, such as having scars or injuries, and whether there are new injuries that may have occurred during the time the patient was transported to the hospital. The Act is very specific about this. They also meet with police in local areas.

The Chairperson asked if Ms Bakubaku-Vos had any follow-up questions.

Ms Bakubaku-Vos’ follow-up question was inaudible.

The Chairperson noted that the Department of Social Development would hopefully broaden the Committee’s understanding.

The Chairperson said Ms Bakubaku-Vos mentioned the collaborative approach of other departments, and noted that this latches on to the budget. Is there a new drug master plan?

Ms Dean said that the drug master plan for 2022 had just come out.

The Chairperson said that the Act in itself was important, and the Committee wanted to understand what was on paper and not just how it would transpire in the capacity of the Department. She asked what was expected from the legislative side relating to the budget, and whether this was possible for the Department to implement in this day and age. Does the budget from the National Department account for all these mandates, or do the unfunded mandates from the Department provide for them in this regard? In some cases, is it not easiest to refer these cases to the Health Department, such as in the case of police making arrests? Is there not a responsibility from state departments to alleviate or contribute to relieving the pressure from the Health Department? Looking at the process with the NHI, would the funding and the mandates be contained within the proposed piece of legislation? How will this impact mental health, not only in the Western Cape, but all other provinces?

Ms Dean said that the Health Department was responsible for the medical side of substance abuse. She asked to defer the question to the Department of Social Development. If medical detox is needed, primary healthcare would assist. The person is referred to a district hospital if in-patient care is needed. If there is opioid abuse, the patient would be referred to Stikland Hospital. The COVID-19 pandemic has interrupted a lot of coordination between the various hospitals. Part of putting this on the health agenda is to have a high-level discussion with the COO, Dr Kariem, and all the managers. This will assess whether all the protocols are still appropriate. She did not have enough information on NHI funding, but there have been various discussions. This will be referred to Dr Cloete, and an answer will be provided to the Committee.

Mr M Xego (EFF) referred to slide nine, speaking on the recognised NPOs that the Department is working with. What is the number of funded NPOs that the Department is working with? This information is important to be able to make referrals, particularly from rural areas. All psychiatric hospitals are situated around the metro. While doing oversight visits, they have noticed that staff have improvised in dealing with patients. One of the key issues relates to staff not being able to deal with mental health patients. This is coupled with budgetary issues and the collaborative approach between departments. In the Overberg region, Swellendam Prison, which belongs to the Department of Public Works, is a white elephant and could ease the pressure in terms of facilities. The former York High School Hostel was also requested to be used for accommodation. However, if one looks at the need, many facilities can be utilised. Institutions do not need to be built afresh. One of the key issues is patients who are confined. There have been many suicides due to the lack of visits. He knows that the number also increased during the COVID-19 lockdown because there was no movement. Now that the Department has noted that suicides are increasing, are there any preventative measures to ensure that suicides decline?

Ms Dean said that what is wanted for the collaborative community is to have a space to talk about unity and whether NPOs need support. There are NPOs that the Department partially funds. Other funding happens between the Department of Health and Social Development. She assured the Committee that community mental health had become a big focus in the Department. The Department would provide the Committee with a list of NGOs.

On vacant buildings, Ms Dean said that she did not have specific knowledge of the Overberg or George area, but this discussion will be taken up – on how the Department can offer support, and what resources are available. This is noted and will be taken up with the directors.

Suicides are worrying. The Mental Health Steering Committee is attending to this to focus on Nyanga and Gugulethu. The focus is on the gaps and how the Departments can interconnect, as this was a worrying statistic – especially for our youth.

The Chairperson said that she understood that Ms Dean was making a distinction in terms of roles and responsibilities and where the Department of Health fits in. However, she wanted to establish whether, based on what the Committee has observed, the Department of Health, being the custodians of national legislation and implementation, received an adequate budget to do what is expected of it in terms of its mandate.

Ms Dean said that the instance of substance abuse psychosis is a huge concern. If this can be prevented, the space can be used for other patients. The resources and burden are not matching up.

Ms Windvogel referred to slide 27 on the mental health mapping pilot. She asked what the terms of reference were. When did it start, and when will it be rolled to communities? She asked about statistics for staff with mental health issues, and if Metropolitan was the only service provider. She said that negative feedback had been received on Metropolitan and staff was not using them anymore.

Ms Dean said that she did not know about the incident of staff issues off hand, but would respond to this in writing. She said that not all staff would present when they needed support. The HOD steering committee started at the end of February and convened every two weeks. Dr Cloete chairs the committee. Dr Macdonald also sits on the committee and the departments of Art and Sport and Education. The Department of the Premier provides the governance for that space. There are four subcommittees. One of them looks at evidence-based interventions, which works with many universities on this. A subcommittee looks at the data of all departments, including data on staff members, as they need to be strong enough to deal with what they need to.

Looking at wellness, they want to include everyone in the community. There is a community mobilisation approach, and they report to HODs on this every two weeks. There is an implementation task team that did a theory of change; it now needs to come up with a wellness strategy to first know what is currently available. This is happening right now, and it began with provincial government Departments. Following this, it will go to faith-based organisations, NPOs, and then the community. Dr Cloete and the HODs will receive a report by the end of October, on progress in this space.

The Chairperson thanked the Department for welcoming the Committee on its oversight visit. She said that the Legislatures had the powers to influence legislation that the Department was required to implement. This was how it intended to approach other spheres, moving forward – so that the legislation, which might hamper or impact the budget or roll out of work, can be attended to by the Committee.

She asked if the Department had anything else to contribute or inform the Committee about.

Interaction with the public

Ms Charlyn Goliath, Valkenberg  Hospital, said that the Department needed to prevent people from coming in and being able to discharge patients. There should be an intervention that extends beyond the individual to the whole family and society. There could be more beds and staff, but the hospital would not be able to discharge people. Her biggest request was for the Committee to get appropriate preventative services where all the Departments work together to support people in maintaining and preventing mental illness and ensure appropriate rehabilitation services in the community. The Hospital also wants to ensure that, when a safety net is needed, it is able to discharge people. What affects the hospital is the Mental Healthcare Act and the Criminal Procedure Act. This makes it difficult to discharge state patients. The number of patients that get admitted is equivalent to a new ward. This comes back to the question of what rehabilitation is for state patients, and how all other departments can support active rehabilitation of these patients.

Ms Estelle Silence, Stikland Hospital, said that the hospital deals with the provincial geriatric services. The complexity around this specifically is the protection of assets, the vulnerability of the geriatric patients and the hospital’s connectivity in terms of the Department of Justice. Stikland Hospital needs to start processing curator applications for the patients before they are discharged. The hospital is providing a service that can be offered in the community, but because the person is vulnerable and does not have a place in the community, they remain vulnerable and in the hospital. The curatorship application process is not prioritised by the Department of Justice. Patients cannot be discharged to facilities that are not licensed and registered. She understands the need and responsibility to ensure that people receive the appropriate care. The hospital does not want a ‘Life Esidimeni’ situation in the Western Cape, but then these facilities need to increase, as someone has to pass away before another person can move into the vacant space. This means that the District will complain and be frustrated to find patients sleeping on the floor. They cannot just turn patients away; they deal with humane issues. A psychiatric patient does not always have the ability to make the best decisions.

Mr Evan Swart, CEO, Mitchells Plain District Hospital, said that the hospital received a lot of acute admissions. High-risk and vulnerable patients are transferred as soon as possible. When there is drug-induced psychosis, it takes a bit longer, as they then need to be transferred to primary healthcare. The situation in Mitchells Plain is similar to Khayelitsha, although Stikland Hospital has a purpose-built 30-bed psychiatric unit built in 2014. In 2016, the hospital split male and female patients with Lentegeur Hospital due to space issues. Females are kept at Lentegeur. This takes extra resources and extra nurses are needed. The number of doctors stayed the same. Over the last two months, since load shedding level six came into effect, the hospital uses a diesel tank of 10 000 litres and also services clinics in the area. The first order to fill the tank was R234 000. In the past week, another order was signed to fill the tank for R240 000. A total of R500 000 was spent in the last two or three months, when there are other needs in the area.

Some contributing factors to high occupancy include chronic diseases, trauma, and alcohol abuse, which contribute to violence and GBV. Familial breakdowns also contribute to mental health. Gang violence, unemployment and socio-economic factors play out in the mental health spaces quite often. There are backyard dwellers, and housing factors also play a role. There is poor adherence to a care plan with patients, which creates the revolving door effect. There could be more rehabilitation spaces. Males are more affected than females. The risks are patient and staff safety, as the types of patients in the ward are unknown. There have been collaborative meetings with doctors three times a week to see what the pressures are and move patients around. Bed occupancy rates have been reduced. Working with Lentegeur hospital means that Mitchells Plain can move faster. This means that they can deal better with patients that have bipolar, schizophrenia and mood disorders that are not self-induced. The answer is not always getting more beds, but getting intervention.

Mr Warren Caesar, CEO, Lentegeur Specialist Hospital, echoed what his colleagues had said. He said that Act 70 of 2008 still speaks to substance abuse, which needs to change. The word abuse is what creates a stigma in communities. This can be changed to substance use disorders. So many lanes have been built on the N2, but one would still find themselves backed up in traffic. Everyone has looked at what they can do differently. “Their team has had to start recognising that patients are our clients and we need to respond to their needs. We need to look at the causal, upstream factors. Most issues are related to substance use, and we need to look at how we can stop this. Community-based workers can be capacitated to take action when a client has not complied with their treatment plan, and then be referred back to the hospital”, he said. He was happy that there were leaders in the space to bring solutions, but said that other role players needed to be brought on board.

The Chairperson asked about the amendment to the Act, and how it will impact on mental health.

Mr Caesar responded that the psychology fraternity had done quite a bit of work. Simply changing the word ‘abuse’ to ‘use’ removes the stigma. People will not seek help because of the stigma, and this will cause them to go further down the rabbit hole. This is a use challenge and not an abuse challenge.

Ms Kiewiets said that she was personally involved in a situation relating to this. It will not be helpful if mental health problems cannot be identified in the workspace where people go for treatment. She said that if the person receiving the patient is not well, they can prevent many situations. They need to clearly define what wellness is. There is a clear indication that mental health in the workplace is a very serious issue. Have training organisations amended their training, and has this been upskilled, because the home-based care training was done in 2002 and 2003? Community-based workers are not trained in mental health. On the previous Monday, an organisation approached her about literacy on mental health issues. If they are co-create knowledge and collaborators on mental health, they need to ensure that they are all on the same page, moving forward. Are community-based organisations equipped to identify the needs around mental health? When community members present at the facility for appointments, she hopes this has changed at a primary healthcare level where there is one mental health nurse for three different health facilities – is this acceptable?

30 patients are waiting to see one psychiatric sister, and at another facility, an incident occurs where another patient cannot be assisted. The rural district clinics are Paarl, Worcester and George. Paarl is the catchment area for the West Coast. No facility is mentioned for the West Coast, and Paarl is the drainage area. This questions how seriously mental health is being taken. Looking at the Drug Masterplan, are we at a district or provincial point with this? In the last discussion about it, the plan for the local level was not completed. “Implementation is always a challenge, and we need to look at how to implement the drug plan at a local level”, she said.

Ms Dean said that she would follow up on the formal training for community-based workers. Literacy is an important issue. George Hospital had ten beds, and this total has almost doubled. There is a full multi-disciplinary team here. There should be at least one mental health nurse per CHC. The mental health nurse should only see the most complex cases. Complex cases can be devolved, and more resources are needed so that the general can see mental health patients more.

The Chairperson thanked the Health Department for its responses, and then handed over to the Department of Social Development for its presentation.

Briefing by the Department of Social Development: Social determinants that apply pressure to the health system specifically in Khayelithsha and Mitchell Plain

The Department said there is an in-treatment centre at the Department of Social Development, and here and there, 30 female adults are accommodated. A facility for males is being built. There are in-house Child and Youth Care Centres, various awareness programmes for substance abuse and a youth facility that can accommodate fifty children.

Due to the significance of the problem, communities want such facilities. However, it is simply not possible to have this in every community.

Community-based interventions are concentrated in the metropolitan area, but they are accessible, as people can be transported to the facilities. This will be taken to IDP forums, and the District Model can assist with this. The Department received six facilities for GBV issues, but they were not operational and needed a lot of work to become operational.

[See presentation for more details]


The Chairperson said that the Committee would like a broader understanding of the issues.

Mr Xego said that it was clear the healthcare workers worked under challenging circumstances, which were exacerbated by the lack of resources. He then asked about the stigma attached to people. The challenge in society is that people are not using the facilities because they fear being stigmatised. He said that it would be wrong to say the Departments were failing. How does one publicise and market the institutions? He asked for more information on how much capacity each institution had to identify where help was needed. Finally, he asked where the GBV shelters could be found.

Ms Windvogel asked how the departments could be brought together to assist each other. During the Committee’s oversight visit, Members heard that some patients are ready to be discharged but have nowhere to go. Is it possible for the Department of Social Development to take over to assist these patients once they are discharged? She then asked about the safe houses in the metro area. Are there plans to have more safe houses? People are sleeping in front of the doors of the safe houses to secure a space for themselves.

The Chairperson said that once an individual is classified as a mental patient, they cannot be classified as a safe house patient. She asked for some more insight into this. She asked about the social factors contributing to the health system being overburdened. What are the budgetary allocations for crime, victim support services and funded substance abuse services? Are there any programmes where the Department of Social Development works with the Health Department for mental health services specifically?

DSD said that services are marketed on the website and via the call centre linked to the GBV call centre. The Department then follows up on these cases and reports back on finalisation. There is a special focus on substance abuse disorders. There is a programme called Ke Moja. This would have been launched in schools, but they are going into exams. This still needs to be worked out, but it will be implemented. The Department also works with SAPS, which is launching a programme called ‘Make Sport Your Game’ to help children avoid gangsterism. Various platforms and social media are used to market, and the requisite strength lies in partnerships. The Department works with NGOs that service community service organisations. The Department of Criminology at UCT made a presentation on gangsters in Khayelitsha and what drove this type of culture. The conclusion was that it was about safety – if one did not belong to a gang, one was not safe. Status was also a factor. Such children were not attending schools, and it was understood that they were dropping out of school. The Department is looking at working with the Department of Education to prevent children from dropping out of school, but rather finding out what they may be interested in, such as plumbing, and assisting them to do this. Social workers in education are spread thinly. The Department would like to capitalise on the victim empowerment forum. He said the Department would like a referral pathway with the Department of Health. When a patient is released, their family or Social Services must be alerted so that this can be resolved if they have nowhere to go. There are serious mental health issues in America, and they have a lot of budget to deal with this, but this is not the case in South Africa. Mental health issues need to be elevated as a serious challenge.

A representative from the Department of Social Development said that the Department was currently working on many topics such as mental health, and there is a mental health Steering Committee meeting held by the HODs. There is an inter sectoral committee where children with disruptive behaviour are discussed. The Department of Social Development, the Department of Health, and the Department of Education all participate in this committee to determine where children end up.

Ms Bakubaku-Vos said that, during the Committee’s oversight, Members noted that there was a girl ready to be discharged, but there was no one to fetch her, which caused her to become furious and isolated. In 2001, a patient had a mental health problem in Lindelani Kopi. Are children like this still taken in?

DSD said that each shelter in the province is owned by NGOs, and there are no government shelters. The buildings donated by the Department of Public Works are managed by NGOs. The Department of Social Development staff does not manage shelters. It is very difficult to send or retain staff in rural areas. A shelter is not different from a clinic or police station, as it will always be there. Youths between the ages of 16 and 24 are driving crime and are also victims. There is no budget to assist such children. Domestic violence increased during the COVID-19 lockdown, because people could not stay together. The Department launched what it calls Courageous Conversations. This is so that staff can understand the challenges communities are faced with. There is a tendency to say people should volunteer, and there are not nearly enough volunteers, because people need money to support themselves. Implementation is also an issue. He said that they heard that about 23 000 parolees were released. Victims and neighbourhood watches were not informed of this. The Department now had to close this gap to facilitate integration into communities.

A representative from the Department said that there are different centres and children with mental health challenges are accommodated. She said almost 80% of children have mental health challenges. There are huge issues with maintaining assets and dealing with children who are in the facilities but do not have mental health challenges and are there for other reasons. There are nurses in the facilities, but the challenge is overcrowding. “We struggle with placing children after they have been treated”, he added.

The Department was in the process of receiving comments from stakeholders. This document will be sent to the Committee once it is available.

The Chairperson asked if the Department of Health had anything to add.

Ms Silence said that Lentegeur Hospital sees adults and children, and the same applies to Stikland Hospital. She asked what the service area was for males, females and children, but more specifically, males in the Khayelitsha area.

Mr Swart said that he knew two areas where patients could be referred. These facilities are always full, but the Department of Social Development supports them. This poses a challenge to the referral pathways. The Steering Committees must work together to improve the determining factors. There are two cohorts of patients who will be discharged. One cohort will be referred to a tertiary facility, as there may be deep-lying mental health issues. Others will return to the community, as they may have ended up in hospital due to intoxication or drug abuse. “We need to figure out where we should send such patients”, he said.

Ms Dean said that it was true that Departments were working together. Such partnerships would deepen. The problem with children getting stuck in Lentegeur Hospital particularly needs to be addressed. The departments are looking at it.

She thanked the Committee for the opportunity.

Ms Kiewiets asked about the Khayelitsha and Mitchells Plain areas, and whether there was an estimate of the number of youths that have been in conflict with the law. What is the number for the in-take in the Chrysalis Academy Programme? The officials spoke about Community Development Workers and Community Health Workers, and the Department of Social Development is aware of this issue. How serious are we about addressing the social ills at traffic lights, parking areas, and also dropouts at school? She commended the Department of Health, as there were soldiers on the ground where the Department of Social Development did not have these. The referral pathway versus the Social Worker reality for communities is an issue. There is a family constantly at the traffic lights in the Belhar area. She referred the matter. Almost a year later, the father and three children are still at the traffic lights. Are we serious about addressing child vulnerability and its impact on children? These children are possibly being used to sitting at the traffic lights, as there is no other alternative. Looking at Khayelitsha and Mitchells Plain, Delft can also be considered because it is the most integrated population in the metro and possibly in the province. Despite having the same issues, Delft does not get the same attention as the other two areas.

Looking at family interventions, the Department of Social Development is not spending the budget it has for its family programmes. Is it serious about family integration and addressing the mental health challenges within families? She said that she has seen that cultural families do not understand, and they think their children are bewitched. How do we ensure an integrated programme between the different sectors and groups? What role do NGOs have within the inter-sectorial cluster? “It is good to talk about us, but if we are not part of the discussion, how would we minimise the complexities we are faced with in communities?”

Mr Caesar said he wanted to reflect on how things were done during the COVID-19 pandemic. During this time, real operational meetings were held between various departments that came together and engaged with communities to create solutions. While 100% of the target may not have been achieved, a lot was achieved. If Lentegeur and the Department of Social Development have challenges, can we not come together to find organisational programmes to respond to all the challenges? He asked if everyone could move into an action space. On the previous day, he attended a Health Indaba. One of the challenges identified was the political will to proceed. Can someone from the Standing Committee intervene to ensure a plan to pull together various stakeholders is realised? “Take our hands, come beside us and let us do this together”, he said.

DSD thanked Members for their questions and inputs. He said it would assist greatly if area-based teams looked back at the lessons learnt during the COVID-19 pandemic. The real challenge is on the ground. The family at the robots in Belhar should be raised as a problem with the Minister so that there is an obligation for staff to go to the area and investigate to ultimately resolve the matter. There are serious matters in the Delft Community. There is no court in the area. After a certain time, the Department of Social Development is unavailable to the community. A number of issues were raised at the imbizos, but there is a need to monitor implementation. The crime prevention strategy is informed by the family and a lot of dysfunctionality revolves around the family. Prevention programmes, reunification and reintegration and budgets should be looked at again. Substance abuse programmes are extended to people who live on the street and in shelters. The population of people in shelters is growing. The Chryslers Academy Programme is funded by Community Safety, and the main focus of this is the youth who are at risk. The Department is reluctant to work with youth in conflict with the law. They are now coming to the initial stages of working in joint programmes with the Department.

The Chairperson said she would leave this to the Department of Social Development to follow up on. She said this was a start and it was important for the Committee to see what was going on in the facilities and to formally start the conversation on this today. The mental health challenges require an integrated, holistic approach of many departments and stakeholders. If such a change cannot happen on a provincial level, this should be addressed on a national level.

The Chairperson thanked all present in the meeting and said this was the beginning of a meaningful engagement with everyone. Other stakeholders would be invited to the next engagement which would be much broader, to have the necessary outcome.

Committee resolutions

 [Inaudible crosstalk @ 04:00:57].

There is discussion, amongst Members, about the Department obtaining a certain building. The Chairperson said that the acquisition of buildings should take place for the financial year, so they could be utilised as safe houses.

Ms Windvogel said that the DSD should provide the Committee with a breakdown of the Auxiliary Social Workers, how many of them are in the province, and which areas they are based. The Committee needs to initiate the engagement with HODs from the different departments.

The Chairperson said that, in the coming week, a draft programme on this matter should be drafted to see who will be included in discussions and where Ministers and HODs can be included.

The Committee must look at the process to propose amendments to the relevant legislation from the Western Cape. The Committee must get a briefing on the Act before amendments can be proposed.

Mr D Plato (DA) said that he concurred, and he asked if the Committee Secretary could provide him with a summary of the issues pertaining to Social Development. There was a study group meeting about it in the morning, to focus on the latest issues in the following meeting.

Consideration and adoption of Committee Reports

Draft Committee Report on the COVID-19 Stakeholder Engagement in Mitchells Plain on 15 June 2022

The Chairperson asked if Members had any inputs.

The Committee adopted the report without amendment.

Draft Committee Report on the Joint visit of the Standing Committee on Health and the Standing Committee on Social Development to the Overberg District from 22 to 24 June 2022

The Committee adopted the report without amendment.

Draft Minutes of Committee dated 29 July 2022

The minutes were adopted without amendment.

Draft Committee report on its Visit to Khayelitsha and Mitchells Plain District Hospitals on 03 August 2022

The report was adopted without amendment.

Draft Minutes dated 05 August 2022

The draft minutes were adopted without amendment.

Draft Committee Report on its Visit to Lentegeur and Valkenberg  Psychiatric Hospitals on 19 August 2022

The report was adopted without amendment.

Draft Minutes of meeting held dated 12 August 2022

The minutes were adopted with amendment.

The Chairperson made brief closing remarks, and said that Members could submit any other inputs to the Committee Secretary by Monday morning.

The meeting was adjourned.


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