The Committee was briefed in a virtual meeting by the Western Cape Department of Health and Wellness on the surge in mental health cases and the programmes in place that addressed mental health care in the province.
The Department reported that although they had already conducted the same presentation last September, they wanted to provide more context and an update on the mental health strategy since their last interaction.
Mental health care in the province had been elevated to a strategic focus, with extra resources granted by the Provincial Treasury. R30 million in additional funding had been provided. The Department focused on access to quality health care with all its partners. The long-term strategy was about a wellness approach that started from before a person was born and extended to old age. A specific focus on including mental health care as part of primary health care had been incorporated into the strategy.
The Department was cognisant of capacity constraints at the primary level insofar as mental health services were concerned. Some primary healthcare facilities did have a mental healthcare nurse, though the health system had been inundated with rising incidents of mental health in the Western Cape. This new trend should also be seen within the context of rising substance abuse problems in the province.
The Department envisaged a system with a dual function at the primary level, where a person consulting a health practitioner for a physical or chronic ailment could also be mentally assessed to determine whether other factors played a role in the person's condition.
Members spoke about their previous oversight visits to psychiatric institutions and the concerns raised by the managers of these institutions. They had all complained about the lack of support from sister departments such as Social Development, Education and the Police.
Update on provincial strategy for mental health
Ms Carol Dean, Director: Specialised Hospitals, Western Cape Department of Health (DoH), said the provincial government had introduced Health Care 2030. The plan focused on the steps required to address the burden of disease, increase the wellness of communities and ensure patient-centred quality care.
The plan had four pillars:
• A person-centred approach;
• Integrated provision of care -- various health professionals working in a cohesive manner with the patient;
• Continuity of care -- continued support for the patient; and
• A life course perspective, meaning a holistic approach and treating patients throughout their lives, not once-off interactions.
The aim was to treat the patient holistically, make them aware of how their decisions influenced their health status, and improve their overall quality of life.
As part of the plan, the Department would also strengthen its advocacy role through wide engagement with other departments and stakeholders outside of government, focusing specifically on improving mental health care.
This was because the Western Cape Government recognised that it could not tackle these challenges alone. A whole-of-society approach was needed, including all three spheres of government: the private sector, civil society, communities and citizens.
The 2030 plan built on the comprehensive service plan of Health Care 2010 by further strengthening community-based services (CBS), primary health care (PHC) and district hospitals, and looked at how the Department would work within this platform to address mental health care provision adequately.
The framework was developed by focusing on three main areas:
• Changes, including opportunities and threats in the external environment, such as advances in technology and a change in the availability of resources;
• Building on the lessons learnt from the comprehensive service plan (CSP) of 2010; and
• Fresh thinking about a re-imagined future.
Mental health care had been repositioned, given the rise in mental health conditions in the Western Cape and the suicide scourge.
(See attached document for details)
Ms R Windvogel (ANC) noted that the presentation was powerful, even though the presenters had already presented the same presentation last year. The information -- especially the additional information -- had been very helpful.
She gave her full support to the vision of a public health system that responded to the needs of citizens in an equitable and accessible manner, as indicated on Slide 9.
She said the ANC had always called for a people-centric and equitable public healthcare system, yet everyone knew this was only for appearance. People were still sleeping on floors and a whole host of other challenges still faced the healthcare system in the Western Cape. The presentation indicated what should be in place for a person to access healthcare.
The policing needs and priorities report of the Western Cape indicated a rapid rise in substance abuse disorder in the province. It also showed that it was a leading cause of crime in the province, and a lack of rehabilitation centres hamstrung efforts to curb this. Drug addicts were then sent to hospitals, which placed additional pressure on hospitals which could have utilised those hospital beds. She asked what collaboration the DoH had with other departments that dealt with this problem.
Slide 17 of the presentation dealt with the rise in suicide incidents in the province. What was being done to stem this worrying trend?
Slide 23 dealt with primary healthcare facilities and their role in mental healthcare. Ms Windvogel wanted to establish how these would be resourced in terms of beds and staff.
Mr C Fry (DA) touched on slide 21 (diagnosis categories), and aligned himself with Ms Windvogel's comments on substance abuse.
Schizophrenia had increased at the same time that the province had also experienced an increase in substance abuse. Had any correlation between these two issues been found, and what processes had been devised that would address these challenges?
Referring to the four listed projects in slide 29, he asked for more information on the projects and the envisioned funding and expenditure on them. The slides contained only a description of the various projects, and no detail.
Mr Fry also recalled an oversight visit to the Paarl Provincial Hospital. The visit had occurred on a Friday evening, with the purpose of checking on the emergency ward. During the visit, they ascertained that 16 beds were in the overstay, and only six were used, as the ward had only one nurse. The irony was that in the psychiatric ward, beds were in demand yet not utilised. The Committee had then resolved to engage with the hospital's chief executive officer (CEO) on some of these developments they had witnessed. This, in essence, sheds light on the comments by Ms Windvogel.
Ms A Bans (ANC) said that she would ask only one question, which also touched on the increase in mental health related cases in the Western Cape.
She also recalled an oversight visit to Khayelitsha District Hospital, where they had found several cases. The visiting delegation had been told that a mental health unit was under construction, but no information on the completion of this project had been forthcoming.If this was the situation at the Khayelitsha hospital, she shuddered to think what the situation could be like at other facilities across the province, especially those in rural areas. People within the urban areas had direct access to mental health facilities like Valkenburg.
Another problem had presented itself in the form of vandalism perpetrated by psychiatric patients in the hospital wards. How would these bottlenecks be addressed, as well as the Department’s strategy to combat these bottlenecks?
Ms N Bakubaku-Vos (ANC) wanted to know about the programmes that had come out of the intergovernmental steering committee and how much the budget had been allocated to mental health programmes, because Members were tired of "talk shows."
Plans were also afoot to open rehabilitation centres in residential areas so that could be more easily accessible for patients. To what extent had the Department supported this proposal?
Ms Dean noted Ms Windvogel's comment about the province's vision to have a Department of Health that was people-centric.
On substance abuse, she said that when a person sought medical care, they were admitted to a hospital as an "acute admission" in terms of the Mental Health Care Act.
Up to 50 % of patients in a mental health ward might present with psychiatric illness, yet the underlying problem is substance abuse. A patient would first be stabilised and attended to, after which the substance abuse issue would be tackled. Patients were referred to a substance abuse facility operated by the Department of Social Development (DSD) after acute hospitalisation.
She had heard the comments about psychiatric patient bed occupancy in wards, and stressed the need for them to receive medical care first. Referrals directly to rehabilitation centres were not always the right course of action. She conceded that beds were under pressure
The Mental Health Care Act prescribed that district hospitals like Khayelitsha and Knysna were assessment centres for those who sought psychiatric medical care. From there, they would either be admitted to a hospital ward, sent for rehabilitation or referred to an Opioid Treatment Programme (OTP) centre.
Psychiatric patients were, on average, admitted for longer in district hospitals. This was undesirable, though the Department had to comply with legislative prescripts. A policy change had been proposed to shorten hospital admission for mental health care patients at district hospitals like Khayelitsha so that patients could progress to the next level.
The next level was also full. Years ago, the Department had not seen such high occupancy numbers. The scenario meant that people at Lentegeur would have to be discharged to make way for the Khayelitsha referrals, not forgetting those from Helderberg, Worcester and other districts.
There was a commitment to work on a flow of the service that enabled patients being
discharged whole and referred to a primary health care, OTP or community health care facility for counselling services.
She commented that the Department of Social Development was responsible for substance abuse rehabilitation centres.
Members would be provided with suicide statistics for the Western Cape and how they compared to other provinces. The cited statistics came from forensic pathology.
She said that part of the work conducted by the mental health care steering committee chaired by Dr Keith Cloete, the Head of Department (HOD), focused on children and adolescents.
Guidelines explored by mental health care advisers called for greater synergies between the government and civic formations like recreational clubs (sports, arts and culture centres etc) and other entities where children and adolescents met. This would allow for greater attention to the mental health care needs of children and adolescents wherever they met.
Children seldom came to healthcare facilities on their own, let alone with their parents or guardians. Children would mostly be found in the education sector. The Department was investing in a children’s and adolescent programme where these targeted groups could receive balanced mental health care, coupled with acute medical care at primary health care facilities as well.
When somebody visited a primary health care facility with a backache, for instance, it was incumbent on the medical practitioner to also ascertain the mental health state of a patient. Sometimes mental health issues manifest themselves physically.
Many of the province's primary healthcare facilities had a dedicated healthcare nurse. If the general nurses could not deal with a patient anymore, he or she could refer that patient to the mental health nurse.
A couple of years ago, the Department had not seen the numbers that were prevalent these days, and of course, substance abuse did not help the situation either.
In most cases where there had been suicide attempts, it obviously indicated that these people were the illest of the ill and needed the Department’s assistance. In other instances, many people were functioning in society, had not sought help for their psychiatric illnesses, and were coping with it as best they could.
Members were also informed that vandalism continued to be a big challenge to facilities. The Department was concerned about this and continued to be kept abreast of developments. She said the Department tried to be dignified in its conduct and operations.
Ms Marinda Roelofse, Deputy Director: Specialised Hospitals, DoH, said that the biggest challenge had been healthcare users not taking responsibility for caring for themselves. When a person was admitted for a possible psychosis, the biggest challenge -- regardless of which department was involved -- remained that people were not taking good care of themselves. The Committee had to be mindful that all patients admitted with possible psychosis had to be kept in the hospital for four days.
The challenge, however, was that these patients would be released back into the very same environment where the problem existed. This of course made it difficult for people to fully heal. The Department had engaged with youth who confirmed this situation.
Avenues had been explored of how the Department could capacitate and strengthen its responses. A study was done in Khayelitsha, Helderberg, Mitchells Plain and the Lentegeur areas, and it was found that only 11% of people discharged were doing well.
Whenever healthcare workers tried to visit other discharged patients, they were often prevented from entering their homes, as the person might be back on the street or could possibly have moved to another province. This obviously made treatment difficult.
On the issue of suicides and dealing with adolescents' and children’s mental health care, the Department was considering the establishment of specialist clinics and primary health care facilities where these individuals could access mental health care without being stigmatised.
When it came to the construction of new hospitals, Members should be aware that it took about five years for a hospital to be built as it involved various spheres of government, so the whole discussion should be about how the government could facilitate a much speedier process.
The Chairperson asked if it was possible for the Department to contain what they were dealing with. He also wanted to ascertain how the Department benchmarked themselves, and what the Committee could do for them.
Ms Dean responded that it was a mammoth task, considering that the government was reorganising itself to work more collaboratively. She acknowledged that silos still existed, but were becoming more uncommon. Mental health care was receiving widespread attention, as HODs were now discussing collaboratively funding streams to tackle mental health care in the province. This also required a whole-of-government, as well as society, approach.
On best practices, Ms Dean elaborated that several projects were coming online, and had strong empirical foundations.
The Department, under the stewardship of the University of Stellenbosch's Head of Psychiatry and other academics and role-players, was busy with ground-breaking research in the mental healthcare field, and this would provide much critical insight. The research also attracted foreign interest.
She added that the Committee could assist in keeping the mental health care portfolio relevant and on the legislative agenda. Such actions had yielded positive results for mental health care budgetary priorities in the past.
The task remained a mammoth one, yet the HOD, Dr Cloete, had shown a real interest and commitment to tackle the priorities of the portfolio.
Ms Roelofse recalled her 30 years of experience in mental health care and the response to HIV/AIDS and TB. That same sort of response had been lacking for years regarding mental health care. It was always shoved to the bottom of health care, yet the post-Covid period had laid bare the challenges.
An emotional Ms Roelofse shared her personal experience of being a mental health care provider. Her two children had both been diagnosed with a rare genetic condition. For 18 months, she had struggled with her mental health and required solid support from her husband, her medical aid, and material belongings. But what about those mothers who lived in areas such as Nyanga? Her heart broke at the dire socio-economic realities that limited access to mental health care for so many destitute families.
The province required a whole-of-society approach, and service provision had to be redesigned.
The Chairperson thanked Ms Roelofse for her personal account, which had pointed towards the realities of the situation.
Mr D Plato (DA) said that the meeting had been called as a direct result of an oversight visit the Committee undertook, and the updated information certainly assisted.
Hunger and food insecurity plagued communities, directly leading to youngsters resorting to the drug trade. Covid-19 has seen factories and other businesses decimated, which clearly impacted mental health.
Mr Fry thanked Ms Roelofse for her courage, and said that her story should not be seen as a career-limiting move. He also had a manageable mental health condition and depended on medical aid.
However, there was a time when he did not have medical aid, and this was a very difficult period, so he understood the dire challenges people faced in communities. He also called for a collaborative response to mental health care.
He further touched on the revolving door experienced by mental health care facilities such as the Lentegeur and Valkenberg Hospitals.
Ms Windvogel said that she was touched by Ms Roelofse's account, and it strengthened her belief that things would pan out. The fact that officials had personal experience certainly influenced their response to the mammoth task at hand. They would go that extra mile.
She was grateful for the positive awareness around health and wellness. People talked a lot about a whole of government and society approach, but she felt that much more had to be done at the local level to involve communities in this approach.
She also requested a list of government-funded non-governmental organisations (NGOs) that conducted work in the mental health care space.
Ms Dean commented that the Department had become much better with data management, and said that the Covid pandemic had accelerated this in many respects. This meant that mental health care had also been brought into sharp focus and a mental health care dashboard meant that mental health care for adolescents and children would be strengthened.
A doctor in Mitchells Plain had designed an app that assisted the DoH in tracking adherence to treatment and consultations. The Department had resolved to work more smartly, and in Heideveld, it was working on promising initiatives.
The Department wanted an effective system that worked, and did not have a situation of nepotism and favouritism when it came to accessing counselling and treatment services.
Community health centres were now empowered to assess mental health conditions, with added investments in aftercare. All of the policy guidelines came into force from 1 April. Ms Roelofse said that the current policy called on community healthcare workers to visit discharged patients within 72 hours of a discharge.
Great work was also being done through interdepartmental coordination with the provincial Departments of Education and Social Development.
These replies concluded the discussion, and the Chairperson noted that he could not begin to comprehend the steel the officials must have, given the mammoth task they faced.
Committee resolutions and actions
Ms Windvogel recalled that during a previous oversight visit to psychiatric institutions, the managers there had asked for a meeting with sister departments in the cluster. They had complained endlessly about the lack of support from departments such as Social Development and the South African Police Service (SAPS). She had thought that the meeting convened had been to address those complaints. She proposed an interdepartmental meeting where the relevant stakeholders could thrash out their differences.
Ms Bans said that the Committee had done well to keep the mental health care portfolio on the agenda and hold the Department accountable. Members had been told several times of construction projects and other initiatives, so progress reports should be provided on them. Mental health concerns had exploded and required a thorough response.
She said she had not been part of the last oversight visit, and seeing that Members served on different Portfolio Committees, they could also drive the process there. There would be discord between officials at times, with the Members of Executive Councils (MECs) being out of the loop. Maybe it would be a great idea to have all of these entities appear before the Committee.
Mr Fry proposed that the Committee should conduct more unannounced visits, as these emphasised the Committee’s commitment to its oversight role. It was therefore imperative to have all the departments in one room.
Ms Bakubaku-Vos recalled the oversight visit to Lentegeur and the complaints by the managers there. They had accused the Department of Social Development of not being hands on. This intervention also required the involvement of the respective MECs. She supported the proposal for an announced visit.
Mr Plato touched on the much-vaunted whole-of-society approach, and the methodology underpinning it. Clarity was needed on who should initiate such an approach.
He also asked that the Department provide a list of all the NGOs that received government funding within the mental health care portfolio.
Members also discussed an oversight visit to Ashton, the Nqobela Primary Health Clinic, and the Robertson Hospital. The logistical arrangements would need to be ironed out.
The Committee also considered and adopted the minutes of its meetings on 24 February, 10 March and 23 March.
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