ATC171025: Report of the Portfolio Committee on Health on the State of Mental Health Care Services, dated 25 October 2017

Health

REPORT OF THE PORTFOLIO COMMITTEE ON HEALTH ON THE STATE OF MENTAL HEALTH CARE SERVICES, DATED 25 OCTOBER 2017
 

1. INTRODUCTION

 

In the light of the 2017 Health Ombuds Report into the circumstances surrounding the deaths of mentally ill patients in Gauteng Province, the Portfolio Committee on Health (the Committee) considered it vital to assess the state of mental health services in eight Provincial Departments of Health (Eastern Cape, Western Cape, Free State, Limpopo, North West, KwaZulu-Natal, Mpumalanga and Northern Cape). The Committee was subsequently briefed by Provincial Departments of Health on 07 to 15 March and 07 to 14 June 2017.

 

1.    REPORTS OF PROVINCIAL DEPARTMENTS

 

1. EASTERN CAPE
   1.  ECDoH reported that there are 150 beds for acute patients at Nelson Mandela Academic, Cecilia Makiwane and Dora Nginza Regional Hospitals.
   2. The province has a 1600 bed shortage with most of the beds concentrated in the western part of the province. Plans to mitigate this challenge, include opening 30 beds for acute patients in Libode (St Barnabas Hospital) thus prioritising the eastern part of the province.
   3. There are 60 beds with two NGOs and 700 beds for chronic patients with Life Esidemeni.
   4. Mental health challenges in the Eastern Cape are exacerbated by the recent radical increase in substance abuse, making social service rehabilitation a critical need. There are only two public facilities in the Eastern Cape that deal with substance abuse.
   5. With regard to forensic patients, there are currently 94 state patients awaiting admission and 261 awaiting observation. To address this need and to improve on waiting time, 30 beds will be added at Komati Psychiatric Hospital and also use Komati for observation.
   6. On human resources, there are 1606 filled posts, with 239 that remains vacant (vacancies for psychiatrists, social workers, etc.). ECDoH reported on the difficulty to retain mental health professionals, particularly occupational therapists. ECDoH was of the view that increasing bursaries will serve as a recruitment and retention strategy.
   7. There are three, Mental Health Review Boards each consisting of three members in the Eastern Cape.

 

Observations and Findings

1. The Committee expressed concern on the high vacancy rate and infrastructure challenges particularly the shortage of beds.
2. The Committee was of the view that there was insufficient focus on advocacy on promotion and prevention, particularly on substance abuse amongst young people.
3. The Committee pointed out the need to strengthen intersectoral collaborations to combat this scourge. The Committee raised a question about the availability of a signed Memorandum of Understanding (MoU) between the ECDoH and the Department of Social Development.
4. The Committee pointed out the need for mechanisms and systems to monitor and evaluate mental health services in order to prevent challenges.

 

1. WESTERN CAPE
   1. WCDoH reported that it welcomes a review of the Mental Health Care Act as concerns have been raised numerous times around red tape and resources that are severely taxed.
   2. Mental health care service provision in the Western Cape has historically been vertical, specialised and curative focused, leading to poor prevention programmes, limited services on primary health care and consequent increase in numbers of admissions at district hospitals and other hospitals.  WCDoH is making an effort to integrate mental health care into a whole health care system as opposed to a vertical system.
   3. In the Western Cape, community-based facilities providing mental health care service are licensed by the Head of Department (HOD) before they can operate.
   4. There are 750 state patients across the four psychiatric hospitals in the province, providing 2000 beds between them. There are 351 private beds.
   5. WCDoH reported to having the highest lifetime prevalence of mental illness in the country and high substance abuse problem (mainly alcohol and tik).
   6. WCDoH highlighted the need to strengthen adolescent and mental health support in perinatal period, interesectoral solution and strengthening the empowerment of mental health care users.
   7. There is a Mental Health Review Board in the province that is independent and reports to the MEC. The Board has developed a governance and operational charter, a user’s rights charts, brochures, internal reporting forms and snag sheets.

 

Observations and Findings

1. The Committee probed whether there was a working relationship between traditional healers and medical practitioners on mental health. The Committee was of the view that traditional healers may play a vital role in addressing mental health care needs.

 

1. FREE STATE
   1. FSDoH reported that private facilities licenced to provide mental health services in the province are mainly based in Mangaung metro (three facilities) and two in Lejweleputswa and Thabo Mofutsanyana districts.
   2. Priority will be given to the establishment of a fully functional Mental Health Directorate by allocating R3.9 million to compensation of employees and R2 million for goods and services.
   3. There is a district mental health specialist team in the Free State currently serving Thabo Mofutsanyana district. Similar teams will be rolled out in the remaining four districts subject to funding availability.
   4. The Free State Psychiatric Complex is the only specialised psychiatric hospital in the province. There are 877 beds, 760 in use.
   5. Adolescents recovering from substance abuse will be catered for in the 40-bed half-way house in Clarens, managed by the Department of Social Development. 
   6. There are 61 NGOs registered with the Department of Social Development.
   7. FSDoH reported to having several challenges relating to serving mental health patients such as:

• Poor infrastructure (dilapidated facilities);
• Inadequate security;
• Inadequate funding;
• Poor retention of social workers due to outstanding Occupation Specific Dispensation (OSD);
• Scarcity of professional nurses with advanced psychiatric qualifications; and
• High vacancy rate of nurses and support staff.
  1. FSDoH reported that posts were in the process of being filled and in discussions with the provincial training institution to offer advanced psychiatric course.
  2. FSDoH was in discussions on the establishment of patient electronic registration system.
  3. There is a Mental Health Review Board consisting of ten members, which is split into two teams, with one team covering the southern side and the other team covering the north and eastern Free State. A total of 39 meetings were held in 2015/16 financial year.
  4. There are five private facilities licenced to provide admissions of voluntary mental health care users in the province.
  5. FSDoH explained that there is a working relationship with the Department of Social Development to ensure provision and compliant mental health care services. This relationship will be formalised once the two MECs meet and sign a MoU.

 

Observations and Findings

1. The Committee sought details on the number of mental health facilities in the province, day-treatment centres, and community-based facilities.
2. The Committee was concerned about the composition of the Mental Health Review Board, whose composition deviated from what is stipulated in the Mental Health Act. There was concern about the number of meetings held by the Board as opposed to executing its duties.
3. The Committee pointed out the need for mechanisms and systems to monitor and evaluate mental health services in order to avert challenges.
4. The Committee sought details the role of outreach teams in relation to mental health services.
5. The Committee sought clarity on whether research was conducted to determine the cause of mental illnesses in the province.
6. The Committee sought details on the timeframes for the establishment of a fully functional Mental Health Directorate as reported by the province.

 

1. LIMPOPO
   1. LDoH reported that the annual hospital admission rate for mental health in public health facilities in the province was 300 per 100 000 population.
   2. In Limpopo, there are six general hospitals with psychiatric wards and three specialised psychiatric hospitals. There are also two general hospitals with no functional psychiatric wards. The three psychiatric hospitals (Hayani, Evuxakeni and Thabamoopo) has 234, 354 and 365 usable beds, respectively.
   3. Forensic mental health services are provided at Hayani and Thabamoopo hospitals. There are currently 78 panel cases and 171 single psychiatric patients awaiting trial and under observation in Thabamoopo hospital.
   4. A state-of-the-art psychiatric facility is about to be commissioned at Letaba Hospital.
   5. There are also three community-based facilities under the Department of Social Services.
   6. There is no licensed acute psychiatric hospital, and child and adolescent outpatient units in the province.
   7. Half-way houses provide care, treatment and rehabilitation to patients who did not require hospitalisation.
   8. LDoH reported that the vacancy rate in facilities is high, ranging from 60% to 100%.
   9. There are three functional Mental Health Review Boards, located in Capricorn, Vhembe and Waterberg districts. Mopani and Sekhukhune districts Boards are yet to be established. 
   10. LDoH reported to having several challenges relating to:

• Infrastructure which is not suitable for psychiatric services;
• Lack of childand adolescent psychiatric units;
• Lack of forensic observation units;
• Poor network connectivity at hospitals;
• Inadequate budget;
• Untraceable relatives;
• Shortage of core and support staff;
• Community stigma; and
• Overcrowding in facilities as a result of accommodating patients from Mpumalanga province that does not have residential psychiatric facilities.
  1. The provincial Department of Social Development reported that all community-based facilities complied with minimum norms and standards.

 

Observations and Findings

1. The Committee was concerned about the alarmingly high vacancy rate. Clarity was sought on progress in filling all the vacancies.
2. The Committee was also concerned about general hospitals which do not have psychiatric wards, and overcrowding in facilities coupled with the absence of outpatient child and adolescent units. Clarity was sought on mitigation plans to address these challenges.
3. The Committee sought details on advocacy programmes and monitoring and evaluation systems in place as well as a fully functional Mental Health Care Directorate in the province.

 

1. NORTH WEST
   1. There are two specialised psychiatric hospitals (Witrand and Bophelong), two designated hospitals and two 72-hour assessment units in the North West province. In addition, there are three licensed private hospitals that provide mental health services. There are 464 community-based beds. There are no NGOs licenced to provide mental health services.
   2. On human resources, the province has not established a Mental Health Directorate due to budgetary constraints.
   3. There was a Mental Health Review Board consisting of four members whose contract expired on 31 March 2017. A new Board was to resume on 1 April 2017, which will cater for all four districts.
   4. NWDoH reported to having challenges relating to:

• Inability to recruit and retain specialised staff;
• Inadequate funding;
• Infrastructure challenges; and
• Insufficient district mental health co-ordinators to lead preventive and promotion aspects on mental health care.

 

Observations and Findings

1. The Committee was concerned about the reported budgetary constraints, underspending and filling of vacancies, which compromise the provision of mental health care services.
2. The Committee expressed concern around the insufficient district mental health coordinators.
3. The Committee sought details on strategies for promotion and prevention; intersectoral collaborations; monitoring and evaluation systems; the involvement of traditional healers; and the role of community health workers.
4. The Committee raised a question on whether research was conducted to determine the causes of mental health problems in the province and progress made in developing an action plan based on the findings.

 

1. MPUMALANGA
   1. There is no psychiatric hospital in Mpumalanga province. As an intervention, the Department is working with the Mpumalanga Economic Growth Agency (MEGA) to fast-track the construction of a psychiatric hospital in the province.
   2. MPDoH submitted that general hospitals are used to deliver psychiatric services. In light of this, adverse consequences have arisen, such as the mushrooming of unlicensed NGOs as well as compromised safety of psychiatric patients.
   3. MPDoH has contracted Life Esidimeni for the provision of chronic mental health services, with 250 adults’ beds and 20 beds for children. Forensic psychiatric services are conducted at two hospitals (Ermelo and Tintswalo) for both single and panel observations. Mental health care users that need further management from designated facilities are referred to psychiatric hospitals in Gauteng.
   4. Between 2014/15 and 2016/17 there were 315 mental health admissions for persons younger than 18 years and 8 686 for adults.
   5. On human resources, there are numerous unfilled vacancies of psychologists, community psychiatric nurses, social workers, occupational therapists, etc.  MPDoH also indicated that most of the senior positions filled are on acting capacity.
   6. There is one Mental Health Review Board that caters for the whole province. MPDoH acknowledged that the workload of the Board is cumbersome and that there are plans to increase the number of Boards in the province.
   7. Over the medium-term, MPDoH plans to deliver 314 beds from six hospitals. The building of a specialised psychiatric hospital is expected to be completed in 2025/2026.

 

Observations and Findings

1. The Committee was concerned about the mushrooming of unlicensed NGOs and highlighted that this requires urgent attention in order to avert similar tragedy that happened in Gauteng, as it was partly attributed to unlicensed NGOs.
2. The Committee also raised a concern about the high number of vacant positions particularly for psychiatrists, community psychiatric nurses and occupational therapists. Clarity was sought on whether the province had a strategy in place to recruit and retain these professionals.
3. The Committee sought details on a number of issues relating to the role of community health care workers in mental health care provision; interesectoral collaborations; mental health awareness programmes and advocacy; and the monitoring of NGOs that provides mental health services.
4. The Committee expressed concern about the long overdue establishment of the Mental Health Directorate.
5. The Committee sought clarity about mental health care users from Mpumalanga being referred to Limpopo as reported by LDoH.
6. The Committee was concerned about the admission of mental health care users to general hospitals, as it meant patients are admitted and seen by general health-trained health professionals.

 

1. NORTHERN CAPE
   1. Mental health in the Northern Cape is provided by government and there is one licenced private psychiatrist hospital and one NGO providing limited disability services. Non-complicated mental illness cases are managed at primary health care facilities. There are no community-based facilities for clients with mental illness or profound disability.
   2. NCDoH reported that oversight and hospital coordination was provided by a provincial coordinator, while district mental coordinators are responsible at district level. A limited outreach service to the districts is provided in West End Hospital. This hospital is the main source of support and referral for acute mental illness and is also the only referral source for state patients, forensic patients and child and adolescent mental health services.
   3. NCDoH reported that many of the general hospitals are not meeting the 72-hour deadline for assessment as per the national policy. This was attributed to capacity constraints.
   4. In terms of infrastructure, the province has made funds available for hospitals refurbishment this financial year. The refurbishments are planned for 20 beds in Kimberley Hospital, 32 beds in Old Gordonoa and Upington, 10 beds in Tshwaragano and four beds each in De Aar, Hartswater, Springbok, Calvinia and Postmansburg.
   5. On the new Northern Cape Psychiatric Hospital, construction is expected to be completed in 2018. Once completed it is expected to provide 199 beds.
   6. There is a Mental Health Review Board consisting of five members that caters for the whole province.
   7. NCDoH acknowledged the mental health personnel capacity challenges and was being addressed through the registrar programme with the University of Free State. The psychiatrists’ shortage was being addressed by rotating the medical officers from the district to the West End Hospital in-service training.

 

Observations and Findings

1. The Committee expressed concern about the high number of personnel in acting capacity in the Department, including an acting HOD. The Committee was of the view that the appointment of a permanent HOD would bring stability and reduce some of the challenges the Department faces. The Committee indicated that this matter should be prioritised.
2. The Committee pointed out that according to the mental health policy, a fully functional Mental Health Directorate should have been established, clarity was sought on the status of this directive in the province.
3. The Committee raised a question on whether NCDoH had approached Treasury for additional funding to fill vacancies.
4. The Committee sought details on budget allocation to mental health; advocacy, promotion and prevention programmes; the causes of mental illnesses; intersectoral collaborations; and monitoring and evaluation systems and mechanisms.

 

1. KWAZULU-NATAL
   1. There are 25 government funded NGOs involved in mental health care in KZN.
   2. Seven (7) hospitals provide specialised mental health care services in the province. District hospitals cater for 5% of the total number of beds reserved for mental health care users and also offer 72-hour assessments.
   3. Challenges faced by the KZNDoH in the delivery of quality mental health include:

• Shortage of psychiatrists;
• Old and dilapidated buildings not fit to provide mental health care;
• Limited budget;
• Lack of community-based services; and
• Rise in substance abuse.
  1. KZNDoH reported to have taken some remedial actions to address the challenges such as:

• Revising the mental health strategy and costs involved;
• Lobbying for more budgets to support mental health;
• Collaborations with universities to increase training;
• Encouraging active participation of family members to support patients; and
• Educating the public about the dangers and prevention of substance use.

 

 

 

Observations and Findings

1.  The Committee sought details on the number of beds for mental health care users; number of mentally ill patients per districts; mental health budget allocation; vacancy rate (mental health care professionals); intersectoral collaborations; prevalent mental disorders; and awareness programmes being implemented.
2. The Committee raised a question on whether NGOs were capacitated and monitored continuously to ensure that they comply with policies.

 

1. RECOMMENDATIONS

 

Having made the above-mentioned observations, the Committee recommends that the Minister of Health should ensure that:

 

1. Human resources
   1. Provincial Departments revise their staff establishments to accommodate the establishment of fully functional Mental Health Directorates.
   2. All funded vacant mental health posts are timeously filled by Provincial Departments to increase the mental health care workforce.
   3. Provincial Departments develop strategies to attract suitably qualified mental health professionals, particularly in rural areas.
   4. Provincial Departments ensure that general health professionals are capacitated to identify and treat mental disorders or mental illnesses on managing them and follow up care.

 

1. Infrastructure
   1. Provincial Departments prioritises the refurbishment and maintenance of existing mental health infrastructure.
   2. Provincial Departments prioritises the construction of mental health hospitals in provinces that have no such infrastructure (e.g. Mpumalanga and Northern Cape).
   3. National and Northern Cape Departments closely monitors the completion of the Northern Cape Psychiatric Hospital.

 

1. Intersectoral collaboration
   1. Provincial Departments establishes strategic partnerships with line function departments (Social Development, Education, Human Settlement, etc.), and other sectors at national, provincial and district levels in relation to mental health care services.  
   2. Provincial Departments ensure that support is provided for community-based services by ensuring that community health workers and NGOs are capacitated to provide quality mental health services.
   3. On unlicensed NGOs, Health and Social Development Departments monitors closely the processes and criteria used to select or grant licences to NGOs.
   4. Provincial Departments ensure that the accreditation process of NGOs is documented and legally authorised.

 

1. Advocacy, mental health promotion and prevention
   1. Provincial Departments embarks on public education outreach programmes on mental health to aid recognition, management or prevention of mental disorders as well as to improve access to care and reduce stigma.

 

1. Research, monitoring and evaluation and oversight
   1. National Department develops and roll-out mental health information systems in provinces which will provide sufficient information to inform intervention decisions and assess quality improvements.
   2. National and Provincial Departments develops a mental health monitoring and evaluation policy together with implementation plans to strengthen monitoring and evaluation of mental health care services in order to mitigate adverse events.
   3. National Department of Health addresses the disparities in the functionality and effectiveness of Mental Health Review Boards amongst provinces.

 

 

Report to be considered.