October 23, 2018

Health Committee scrutinises provincial mental care facilities

Is there another Life Esidemeni tragedy waiting to happen, especially in provinces which have no mental care facilities at all, or hospitals with 100% vacancy rates for mental health care professionals?

Following the ghastly Life Esidemeni crisis in Gauteng in 2017, the Portfolio Committee on Health conducted oversight visits to all other eight provinces to monitor the provision of mental health care services, and be thoroughly briefed by provincial health department officials.

Judging from the Committee report, tabled in Parliament at the end of May, the danger exists of a repeat of the Gauteng Life Esidemeni horror story, and the Committee in its report appealed to the Minister of Health to ensure Provincial Departments establish fully functional Mental Health Directorates and “timeously” fill all funded vacant mental health posts to increase the mental health care workforce. Limpopo, for example, reported vacancy rates ranging from 60% to 100%.

Limpopo has to take patients from Mpumulanga, which has no residential psychiatric facilities at all.

The report considered each province in turn. The Eastern Cape had a shortage of 1,600 beds for mentally ill patients at the time the Committee conducted its visit to this seriously under-capacitated area. The Committee was told that at the time there were only 150 beds for acute patients, at Nelson Mandela Academic, Cecilia Makiwane and Dora Nginza Regional Hospitals, and efforts were underway to open 30 more beds for acute patients at St Barnabas Hospital.

All these medical facilities are found in the eastern part of the province, which leaves the western half facing a serious challenge.

The Committee also heard that with regard to forensic patients, there are currently 94 state patients awaiting admission and 261 awaiting observation, and all that can currently be done to speed up the process is to add 30 beds to the Komati Psychiatric Hospital.

During its briefing with local medical practitioners, the Committee also learned that they have seen a sudden radical increase in substance abuse in the province, yet there are only two public facilities in the vast Eastern Cape that deal with substance abuse.

The Western Cape is another province experiencing high substance abuse, particularly alcohol and tik, but it can provide a level of care with 2,000 beds across its four state psychiatric hospitals. In the Western Cape, community-based facilities providing mental health care service are licensed by the Head of Department before they are allowed to operate and there is an independent Mental Health Review Board that reports to the MEC.

The Free State has one specialised psychiatric hospital in the province. The Free State Psychiatric Complex has 877 beds, and at the time the report was compiled 760 were in use. Adolescents recovering from substance abuse have access to the 40-bed half-way house in Clarens, managed by the Department of Social Development, and 61 NGOs are registered with the Department of Social Development to provide mental health care. The Free State Department of Health works closely with the Department of Social Welfare and a memorandum of understanding is believed to be on the way.

Limpopo has six general hospitals with psychiatric wards and three specialised psychiatric hospitals with 234, 354 and 365 “usable” beds each. Forensic mental health services are provided at Hayani and Thabamoopo hospitals. There are currently 78 panel cases and 171 psychiatric patients awaiting trial and under observation in Thabamoopo hospital. There are also three community-based facilities under the Department of Social Services and an unspecified number of half-way houses.

On the whole, Limpopo appears to be sufficiently capacitated, with a state-of-the-art psychiatric facility about to be commissioned, but existing facilities are overcrowded because Limpopo has to take patients from Mpumulanga, which has no residential psychiatric facilities at all.

A specialised psychiatric hospital is planned for Mpumalanga but building is only expected to be completed in 2025/2026. In the meantime, patients needing mental health care have to go to Limpopo or be admitted to general hospitals that have no specialised psychiatric services. In light of this, adverse consequences have arisen, such as the mushrooming of unlicensed NGOs.

Mental health care in the vast Northern Cape is provided by one licenced private psychiatric 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,” according to the Committee.

Patients must rely on a limited outreach service provided by West End Hospital and collaboration with the University of Free State, which rotates medical officers to the West End Hospital in-service training unit. “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.” A new Northern Cape Psychiatric Hospital is apparently under construction and due to be ready this year. Once completed it is expected to provide 199 beds.

The North West province has two specialised psychiatric hospitals, two designated hospitals and two 72-hour assessment units. There are 464 community-based beds but no NGOs licenced to provide mental health services.

Finally, KwaZulu-Natal has 25 government-funded NGOs involved in mental health care and seven hospitals that provide specialised mental health care services in the province.

The Committee’s comprehensive report reveals a pattern throughout the provinces. The key challenge is the critical shortage of qualified staff, and the inability to retain them. Then there is the lack of beds in specialised psychiatric facilities. Another persistent problem country-wide is old, damaged and poor infrastructure.

Finally, and in light of Gauteng’s experience, there is a demand for close monitoring of NGOs providing mental health services and the need for their licencing process to be rigorous and free of all loopholes.

The Committee is concerned to avoid another Life Esidemeni episode by focusing on community-based health workers and NGOs, given that it was at ill-equipped and illegally registered NGOs that the 144 Gauteng citizens died from starvation, dehydration and neglect.

Yet, the dangers of unlicensed service providers continue to present a risk. The Committee found in Mpumulanga, which has no residential psychiatric facilities at all, that not unexpectedly unlicensed NGOs are “mushrooming” with the related threat of “compromised safety of psychiatric patients”.

“Provincial Departments [must] ensure that the accreditation process of NGOs is documented and legally authorised,” the Committee report declares.

This mirrors the response at ministerial level. One of the first remedies introduced by Health Minister Aaron Motsoaledi after the exposure of the Life Esidemeni disgrace was to gazette new regulations to keep NGOs that look after mental health patients in check. He also issued a policy document of more than 200 pages that provided guidelines for the licensing of residential and daycare facilities for mental health patients.

The Committee’s visits to check on provincial mental health care facilities shows Parliament doing what it is mandated to do, and that is overseeing government delivery, including at provincial level. The National Assembly voted that the report would be considered.

The report includes among its recommendations that:

  •  “Provincial Departments develop strategies to attract suitably qualified mental health professionals, particularly in rural areas.
  • They ensure that general health professionals are capacitated to identify and treat mental disorders or mental illnesses on managing them and follow up care.
  • Provincial Departments prioritise the refurbishment and maintenance of existing mental health infrastructure and prioritise the construction of mental health hospitals in provinces that have no such infrastructure (eg Mpumalanga and Northern Cape).
  • Strategic partnerships be developed to provide mental health care services with relevant departments such as Social Development, Education, Human Settlement and other sectors, at national, provincial and district levels.”

The Committee report calls on the national Department to develop and roll-out mental health information systems in provinces and to develop mental health monitoring and evaluation services. It also proposes that the disparities in the effectiveness and capacity of provincial Mental Health Review Boards be addressed by the national Department of Health.

The Committee wants to see provincial Departments of Health “embark 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”.

Now that’s starting to ask a lot, if you consider that in every province visited by the Committee, it found serious shortages of medical staff equipped to provide even basic care for the mentally ill and disabled.

Moira Levy

Sourced from Parliament’s Announcements, Tablings and Committee Reports, no 68.

Additional Info

  • Author: Moira Levy

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