Towards an integrated Mental Health Service - Health Systems Trust
Towards an integrated Mental Health Service - Health Systems Trust
Towards an integrated Mental Health Service - Health Systems Trust
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
A situation <strong>an</strong>alysis of the Lower Or<strong>an</strong>ge District<br />
INITIATIVE FOR SUB-DISTRICT SUPPORT<br />
By Natalie Grazin
ACKNOWLEDGEMENTS<br />
_______________________________________________________<br />
I would like to th<strong>an</strong>k the following people who assisted with the compilation of<br />
this report:<br />
Sister Elise Muller <strong>an</strong>d Sister Katie Diergaardt, who allowed me to observe their<br />
practice, edited a draft of the report <strong>an</strong>d gave freely of their time.<br />
Lesley Bamford, for her valuable advice <strong>an</strong>d guid<strong>an</strong>ce throughout the project<br />
<strong>an</strong>d for editing numerous drafts.<br />
Sister Lena V<strong>an</strong> der Westhuizen, of the Lower Or<strong>an</strong>ge District M<strong>an</strong>agement<br />
Team, who discussed her pl<strong>an</strong>s <strong>an</strong>d ideas for the future of the service.<br />
Celia Isaacs, the head of West End Psychiatric Hospital, for information about<br />
the hospital.<br />
Peter Barron, who gave advice <strong>an</strong>d edited various drafts.<br />
All the nurses from the primary health care clinics <strong>an</strong>d the hospitals who<br />
participated in the focus group discussions.<br />
Lauren Muller, for bringing her insight of the national context to her editing of<br />
the draft <strong>an</strong>d for her guid<strong>an</strong>ce in developing the project pl<strong>an</strong>.<br />
Andy Gray for advice about nurse prescribing.
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
CONTENTS<br />
Executive Summary<br />
ii<br />
Introduction 1<br />
Chapter 1: Background 2<br />
1.1 History of the service<br />
1.2 District Development<br />
1.3 Socio-economic context<br />
Chapter 2: Psychiatric Facilities <strong>an</strong>d <strong>Service</strong>s 6<br />
2.1 Inpatient services<br />
2.2 Upington psychiatric outpatients clinic<br />
2.3 Psychiatric outreach clinic service<br />
2.4 <strong>Service</strong> to outlying areas (“postal service”)<br />
2.5 Psychiatrist<br />
2.6 Psychologist<br />
2.7 Forensic patients<br />
2.8 Child <strong>an</strong>d adolescent mental health<br />
2.9 Elderly mentally ill<br />
2.10 Learning disability facilities<br />
2.11 Drug <strong>an</strong>d alcohol services<br />
2.12 Crisis/emergency service<br />
2.13 Certification of Involuntary patients<br />
2.14 <strong>Health</strong> promotion activities<br />
2.15 Inter-sectoral work<br />
2.16 Other community structures<br />
Chapter 3: Key Issues <strong>an</strong>d Problems 17<br />
3.1 Prescribing<br />
3.2 Relations with other district health care providers<br />
3.3 Lack of district inpatient facilities<br />
3.4 Lack of information<br />
Chapter 4: Integration of <strong>Mental</strong> <strong>Health</strong> into PHC 24<br />
4.1 National <strong>an</strong>d local context<br />
4.2 First steps<br />
4.3 The role of the district<br />
4.4 The role of the psychiatric nurse practitioner<br />
4.5 M<strong>an</strong>agement <strong>an</strong>d accountability arr<strong>an</strong>gements<br />
4.6 Project pl<strong>an</strong><br />
Chapter 5: Strategy for Future Development 42<br />
Appendix 1: Patients registered with psychiatric service by locality 49<br />
Appendix 2: PHC clinics represented in the nurses’ focus group 53<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
EXECUTIVE SUMMARY<br />
Since 1994, the direction of national policy has been towards the integration of<br />
mental health services into the primary healthcare system, thus ending years of<br />
segregation <strong>an</strong>d stigmatisation of psychiatric patients. National policy also<br />
envisions the development of psychiatric services so as to reflect a broader<br />
definition of mental health, incorporating preventive activities <strong>an</strong>d subst<strong>an</strong>ce<br />
abuse services.<br />
The adoption of these policies brings South Africa into line with the m<strong>an</strong>y<br />
countries around the world who have attempted to re-integrate psychiatric<br />
patients into the community over the past fifteen years. However, the<br />
experiences of countries such as the United States <strong>an</strong>d Britain have<br />
demonstrated the d<strong>an</strong>gers of attempting to undertake community integration<br />
too fast <strong>an</strong>d without ensuring that sufficient resources <strong>an</strong>d skills exist within the<br />
community.<br />
This paper is the result of research which set out to consider the feasibility <strong>an</strong>d<br />
implications of implementing these policies within the Lower Or<strong>an</strong>ge district,<br />
given the pl<strong>an</strong>s of the District M<strong>an</strong>agement Team (DMT) to integrate psychiatric<br />
services into primary health care (PHC) as of the 1 st April 1999. A rapid<br />
situation <strong>an</strong>alysis was carried out during October 1998 by me<strong>an</strong>s of informal<br />
interviews, focus group discussions <strong>an</strong>d <strong>an</strong>alysis of existing data.<br />
The research found that:<br />
• Despite a paucity of resources compared to national <strong>an</strong>d international<br />
norms, Lower Or<strong>an</strong>ge’s limited psychiatric service is robust, accessible <strong>an</strong>d<br />
patient-friendly.<br />
• <strong>Mental</strong> health services within Lower Or<strong>an</strong>ge remain primarily curative in<br />
nature <strong>an</strong>d follow a traditional “psychiatric” model; wider mental health<br />
services are yet to develop. The need for a psychologist is acutely clear.<br />
However, there is widespread enthusiasm for the introduction of activities<br />
aimed at preventing the onset of mental health problems. A schools<br />
education programme <strong>an</strong>d community education are locally regarded as <strong>an</strong><br />
urgent priority.<br />
• Psychiatric services are still org<strong>an</strong>ised vertically from Kimberley; for these<br />
services to be led by the local DMT <strong>an</strong>d involve the local community will<br />
represent a large shift in culture <strong>an</strong>d focus<br />
• At present, there are m<strong>an</strong>y logistical issues which hamper the provision of<br />
<strong>an</strong> effective service within the district. Such issues include problems with<br />
the availability of drugs, tr<strong>an</strong>sport problems <strong>an</strong>d the reli<strong>an</strong>ce upon a<br />
psychiatrist who services the entire population of the Northern Cape.<br />
• Data collection is inadequate <strong>an</strong>d is not tr<strong>an</strong>slated into valuable information.<br />
There is also a paucity of information about the mental health profile of the<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
district which makes effective strategic pl<strong>an</strong>ning <strong>an</strong>d targeting of services<br />
impossible. Existing data suggest a worryingly high number of attempted<br />
suicides at around eight per week in Upington alone.<br />
• There is strong support in principle amongst primary health care staff for<br />
the integration of psychiatric care into primary health care clinic services.<br />
However, m<strong>an</strong>y have concerns about their capacity (in terms of time) to<br />
m<strong>an</strong>age the extra workload without compromising patient care. There are<br />
also widespread concerns that some primary health care staff lack the<br />
knowledge, skills <strong>an</strong>d confidence to undertake care of psychiatric patients.<br />
• As psychotropic drugs are categorised as Schedule 5, there will be major<br />
difficulties in delivering the psychiatric service from PHC clinics without a<br />
ch<strong>an</strong>ge in the regulations which currently prevent PHC clinics from stocking<br />
Schedule 5 drugs.<br />
• Amongst key role players within the district, there are widely differing<br />
visions of how far services need to ch<strong>an</strong>ge. No shared concept of “<strong>an</strong><br />
<strong>integrated</strong> service” has yet emerged.<br />
The key recommendations of the paper include:<br />
• The formulation <strong>an</strong>d agreement of a district strategy <strong>an</strong>d timetable for the<br />
gradual integration of mental health services into PHC<br />
• The re-consideration by the DMT of the 1 st April deadline in order to ensure<br />
that neither patient care, nor the safety of the community, is compromised;<br />
a staggered approach to integration may better safeguard the quality of<br />
care<br />
• A comprehensive training programme for all primary health care staff within<br />
the district to equip them to deal with psychiatric patients<br />
• Training of the DMT to prepare for the strategic m<strong>an</strong>agement of the service,<br />
including the supervision, monitoring <strong>an</strong>d evaluation of the service<br />
• Community involvement in shaping the future configuration of services so as<br />
to gather opinion <strong>an</strong>d explain the notion of “care in the community”<br />
• A re-examination of the role of the provincial psychiatrist within the district<br />
• Investigation of the feasibility of rendering secondary level (inpatient)<br />
psychiatric care within the district, potentially within Gordonia Hospital, with<br />
the aim of m<strong>an</strong>aging the vast majority of patients without referral to<br />
provincial services<br />
• Research to establish the extent <strong>an</strong>d nature of mental health needs of the<br />
local communities so as to facilitate <strong>an</strong> informed approach to service<br />
pl<strong>an</strong>ning<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
• A community education programme involving key role players such as<br />
teachers <strong>an</strong>d church leaders aimed at reducing subst<strong>an</strong>ce abuse <strong>an</strong>d suicide<br />
rates<br />
The implementation of national policy will thus entail <strong>an</strong> immense amount of<br />
work. However, the district is rich in hum<strong>an</strong> resource capacity <strong>an</strong>d there is<br />
overwhelming support for the principle of integration. If approached with due<br />
care, the reconfiguration of services represents <strong>an</strong> opportunity for Lower<br />
Or<strong>an</strong>ge to develop a modern, high quality service.<br />
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Introduction<br />
Psychiatric services in the Lower Or<strong>an</strong>ge region have traditionally operated in<br />
<strong>an</strong> isolated m<strong>an</strong>ner, divorced from other healthcare providers within the district.<br />
The 1995 White Paper, Tr<strong>an</strong>sformation of the <strong>Health</strong> System, emphasised the<br />
urgency of developing traditional, curative psychiatric services into a broader<br />
concept of mental health, <strong>an</strong>d secondly, the import<strong>an</strong>ce of integrating mental<br />
health services into the new, primary-care led district unit.<br />
The Northern Cape Provincial Department of <strong>Health</strong> is working towards<br />
devolution of the care of psychiatric patients to the district level. For the<br />
district m<strong>an</strong>agement team of Lower Or<strong>an</strong>ge, this will me<strong>an</strong> devolving care to<br />
the PHC teams; this tr<strong>an</strong>sfer process is tentatively pl<strong>an</strong>ned to begin as of 1 st<br />
April 1999. This process will have considerable implications for the PHC staff,<br />
for psychiatric nursing staff <strong>an</strong>d of course, for the patients <strong>an</strong>d their families.<br />
Objectives<br />
This paper provides:<br />
• a detailed account of the nature <strong>an</strong>d functioning of psychiatric services<br />
within the Lower Or<strong>an</strong>ge region<br />
• <strong>an</strong> <strong>an</strong>alysis of the key issues <strong>an</strong>d problems facing the psychiatric service<br />
• a suggested list of steps necessary before 1 st April 1999 if the integration of<br />
psychiatric services into PHC is to be successful<br />
• <strong>an</strong> action pl<strong>an</strong> to address the priorities for the development of the current<br />
psychiatric service into a broader mental health service<br />
Research methods<br />
This study was carried out through interviews with the following healthcare<br />
staff:<br />
• the two nurses currently providing the psychiatric service;<br />
• the Chief Professional Nurse at district level responsible for PHC;<br />
• nursing staff from Kakamas <strong>an</strong>d Upington hospitals<br />
• a focus group of PHC nurses from around the district (details of particip<strong>an</strong>ts<br />
in Appendix II).<br />
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1.1 History of the service<br />
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Chapter 1<br />
Background<br />
Community <strong>Mental</strong> <strong>Health</strong> services within the Northern Cape are still org<strong>an</strong>ised<br />
at a provincial level, utilising a classically “vertical” m<strong>an</strong>agement style. The<br />
service has until recently been m<strong>an</strong>aged from Kimberley, with clinical,<br />
budgetary <strong>an</strong>d operational issues all relating directly up from Lower Or<strong>an</strong>ge to<br />
Provincial level. Between 1997 <strong>an</strong>d 1998, some progress has been made in<br />
increasing the operational <strong>an</strong>d budgetary elements of the service’s<br />
m<strong>an</strong>agement down to the district m<strong>an</strong>agement team. The salaries of personnel<br />
working within psychiatric services have for example been paid by the district<br />
office rather th<strong>an</strong> by the Provincial office for the first time. However, the<br />
ordering of all supplies such as drugs <strong>an</strong>d stationary is still administered<br />
through Kimberley. Clinically, the service maintains its orientation directly<br />
“upwards” to the Provincial centre <strong>an</strong>d thus remains fundamentally distinct from<br />
other district health services.<br />
The Northern Cape suffers from a severe paucity of resources <strong>an</strong>d services<br />
within mental health. There is only one inpatient facility for the entire Province,<br />
at the West End Hospital in Kimberley. The Upington clinic is one of only two<br />
psychiatric outpatients clinics throughout the province; the other is located in<br />
De Aar, in the Lower Karoo region. The Kalahari region, Namaqual<strong>an</strong>d region,<br />
<strong>an</strong>d the H<strong>an</strong>tam region have no psychiatric service personnel at all. For most<br />
patients within the province, their only contact with the psychiatric service is <strong>an</strong><br />
<strong>an</strong>nual consultation with a psychiatrist. A system operates by which psychiatric<br />
drugs for named patients are posted from Kimberley <strong>an</strong>d distributed by PHC<br />
nurses. Over the past two years, progress has been made in Namaqual<strong>an</strong>d in<br />
rendering psychiatric services from within PHC facilities.<br />
The psychiatric clinic in Upington was established in the early 1980s. Until that<br />
time, the psychiatrist based in Kimberley offered a service by which<br />
patients could have psychiatric drugs posted directly to their homes. Sister<br />
Muller took up the post of Psychiatric Nurse Practitioner in 1986 <strong>an</strong>d worked<br />
initially with <strong>an</strong> enrolled nurse. A second post, also at Nurse Practitioner level,<br />
was created soon after her appointment <strong>an</strong>d has been filled by a number of<br />
people. Sister Diergaardt took up the post in 1991. The clinic now has almost<br />
700 patients on its register, 500 of whom live in or around Upington, <strong>an</strong>d the<br />
remainder being patients from Keimoes, Kakamas <strong>an</strong>d Kenhardt. Sister Muller<br />
is a Chief Professional Nurse <strong>an</strong>d Sister Diergaart, a Senior Professional Nurse.<br />
A map overleaf shows the distribution of mental health service facilities within<br />
the province which serve the Lower Or<strong>an</strong>ge district.<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
MAP OF MENTAL HEALTH SERVICES WITHIN<br />
THE NORTHERN CAPE PROVINCE SERVING LOWER ORANGE<br />
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1.2 District Development<br />
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
The Lower Or<strong>an</strong>ge region is operating to a large extent independently as a<br />
district unit. It has a full DMT in place which occupies a dedicated office which<br />
is well equipped to allow the team to take full responsibility for the running of<br />
its services. Well developed fin<strong>an</strong>cial m<strong>an</strong>agement systems are in place.<br />
Within the district, clinical services are gradually <strong>an</strong>d appropriately being<br />
tr<strong>an</strong>sferred down from provincial level. Along with mental health, oral health is<br />
identified as one of the few services which has not yet been <strong>integrated</strong> into<br />
district level PHC provision.<br />
1.3 Socio-economic context<br />
There are several socio-economic factors which influence the mental health<br />
profile of the region. The first is the agricultural base of the local economy,<br />
which produces grapes, sun-dried fruits <strong>an</strong>d wine. The wide-scale availability<br />
<strong>an</strong>d extremely cheap price of locally-produced alcohol me<strong>an</strong>s that alcohol<br />
misuse is a common characteristic of patients who develop mental health<br />
problems. The extent of alcohol availability is exacerbated by the “dop<br />
system”, by which agricultural workers receive a proportion of their wages in<br />
the form of wine. It is thought that this system is still in use within the district.<br />
Research suggests that the correlations between alcohol abuse <strong>an</strong>d psychiatric<br />
disorders are signific<strong>an</strong>t: “alcholics” are 21 times more likely to have a diagnosis<br />
of <strong>an</strong>ti-social personality disorder compared with non-alcoholics; 6.2 times more<br />
likely to have a diagnosis of m<strong>an</strong>ia; 4 times more likely to have a diagnosis of<br />
schizophrenia; <strong>an</strong>d 1.7 times more likely to have a diagnosis of depression. 1<br />
Should these correlations hold true within the South Afric<strong>an</strong> context, the<br />
consequences for mental health in Lower Or<strong>an</strong>ge would be considerable. It was<br />
certainly the opinion of all healthcare professionals who participated in this<br />
research that alcohol misuse is indeed a prime cause what appear to be high<br />
levels of mental ill-health within the region.<br />
The second factor affecting mental health within the region is the high level of<br />
unemployment. The 1996 Census found that the Northern Cape has <strong>an</strong><br />
average unemployment rate of 29%. This is only a small improvement upon<br />
the October Household Survey of 1994, which estimated that 32,5% of<br />
economically active people were unemployed. The 1994 survey also found that<br />
unemployment rates were higher for Coloureds (37,9%) <strong>an</strong>d Blacks (39,4%)<br />
th<strong>an</strong> Whites (7,2%). Fifty-seven percent of unemployed people had been<br />
unemployed for more th<strong>an</strong> a year at the time of the survey.<br />
Benefits, pensions <strong>an</strong>d other gr<strong>an</strong>ts therefore form <strong>an</strong> import<strong>an</strong>t source of<br />
income for m<strong>an</strong>y households. Although there are no accurate figures, there is<br />
no doubt that a sizable proportion of the population live in poverty.<br />
1 Helser J.E. <strong>an</strong>d Pryzbeck T.R. (1988), The co-occurrence of alcoholism with other psychiatric disorders<br />
in the general population <strong>an</strong>d its impact upon treatment, Journal of Studies on Alcohol, 49, 219-224<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Finally, there is a strong seasonal variation in availability of work. During<br />
November <strong>an</strong>d December, m<strong>an</strong>y hundreds of migr<strong>an</strong>t workers come into the<br />
area <strong>an</strong>d live temporarily on the farms at which they are working. These<br />
workers represent <strong>an</strong> increasing, if small, proportion of individuals presenting to<br />
the psychiatric services. Their problems are exacerbated by l<strong>an</strong>guage<br />
difficulties <strong>an</strong>d by the absence of a family or other social network to support the<br />
patient <strong>an</strong>d ensure compli<strong>an</strong>ce with medication.<br />
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Chapter 2<br />
Psychiatric Facilities <strong>an</strong>d <strong>Service</strong>s within Lower Or<strong>an</strong>ge<br />
2.1 Inpatient services<br />
There are no psychiatric inpatient facilities within Lower Or<strong>an</strong>ge itself. The<br />
Northern Cape has just one designated psychiatric hospital, the West End<br />
Hospital located in Kimberley, which is around 400 kilometers from Upington. It<br />
has 107 beds, of which around 36 are dedicated to long-term patients with who<br />
have become institutionalised within the hospital <strong>an</strong>d c<strong>an</strong>not be tr<strong>an</strong>sferred out<br />
into the community. The remaining 70 beds are for patients experiencing<br />
periods of acutely mental illness. This number is however signific<strong>an</strong>tly lower<br />
th<strong>an</strong> it was some years ago following the closure of wards <strong>an</strong>d a gradual<br />
reduction in the number of beds over the past few years. The hospital c<strong>an</strong><br />
therefore offer only limited support to the Lower Or<strong>an</strong>ge region. Furthermore,<br />
the psychiatric nurses within Lower Or<strong>an</strong>ge have increasingly attempted to<br />
m<strong>an</strong>age patients within the community; numbers of patients referred to<br />
Kimberley have decreased signific<strong>an</strong>tly over the past ten years. The district<br />
hospital, Gordonia, is located within Upington <strong>an</strong>d provides secondary level<br />
services. It does not however accept psychiatric patients on a routine basis.<br />
The primary adv<strong>an</strong>tage of the West End Hospital over community care is that it<br />
c<strong>an</strong> provide a high level of observation <strong>an</strong>d on-site medical attention from a<br />
medical officer each day <strong>an</strong>d from the psychiatrist when he is in Kimberley.<br />
Patients also have limited access to rehabilitative services such as<br />
physiotherapy <strong>an</strong>d occupational therapy. The hospital has however<br />
experienced great difficulties in attracting <strong>an</strong>d retaining a psychologist; this post<br />
is currently vac<strong>an</strong>t. There are also facilities for the use of ECT as a last resort<br />
therapy. However, the psychiatric nurses in Upington report that it is a<br />
depressing <strong>an</strong>d restrictive environment which itself does little or nothing to<br />
promote good mental health.<br />
The DMT in Lower Or<strong>an</strong>ge believe that some of the budget for psychiatric<br />
services within their region is still allocated to the West End Hospital. Clearly,<br />
there will continue to be some allocation of Lower Or<strong>an</strong>ge funds as long as the<br />
hospital provides some service to Lower Or<strong>an</strong>ge residents; however, given the<br />
gradual reduction in the utilisation of inpatient services at Kimberley, there is<br />
need to review the allocations to each sector of the service <strong>an</strong>d if necessary, to<br />
negotiate adjustments as appropriate.<br />
2.2 Psychiatric Clinic, Upington<br />
The clinic is located in a dedicated building in the centre of Upington <strong>an</strong>d is<br />
therefore convenient for patient access. It is, however, slightly set back from<br />
the road <strong>an</strong>d the entr<strong>an</strong>ce is quite discreet, affording a degree of<br />
confidentiality.<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
The clinic is made up of six rooms, all leading off one corridor. The first is used<br />
as a patient waiting room; the second as <strong>an</strong> office, although it appears to be<br />
used only rarely; the third contains the drug cupboards <strong>an</strong>d the filing cabinets<br />
containing the patient records <strong>an</strong>d is consequently the location for the majority<br />
of patient visits; the fourth is used by the psychiatrist during his six monthly<br />
visits; the fifth is used as a general store room, including the boxes containing<br />
used sharps (see below); <strong>an</strong>d the sixth as <strong>an</strong> additional waiting room during the<br />
psychiatrist’s visits.<br />
The space available to the clinic therefore appears to be more th<strong>an</strong> ample, with<br />
some rooms going unused for the vast majority of the time that the clinic is<br />
open. However, the level of privacy afforded to patients both in the waiting<br />
room <strong>an</strong>d during consultations is minimal <strong>an</strong>d the environment is not conducive<br />
to patient disclosure of sensitive issues or discussion of a patient’s problems.<br />
For reasons of safety, the nurses keep the doors of the rooms in which they are<br />
seeing patients open at all times.<br />
The clinic effectively runs <strong>an</strong> open access service, although a form of<br />
appointment system exists insofar as patients are expected to present on a<br />
regular date within each month. No exact time within the day for their<br />
appointment is stated. In practice, however, the service runs as <strong>an</strong> open<br />
access facility: patients know that they c<strong>an</strong> turn up at <strong>an</strong>y time <strong>an</strong>d see the<br />
sisters (for example, on the day before the clinic was visited, Monday 5 th<br />
October, 21 “appointments” had been made but 38 patients were seen<br />
altogether). There were 499 patients on the Upington register at the end of<br />
September. Details of monthly attend<strong>an</strong>ces are given in Appendix 1.<br />
Patients present with <strong>an</strong>y form of query or problem, or if they w<strong>an</strong>t advice<br />
about <strong>an</strong>ything. The scope of such questions extends beyond concerns related<br />
directly to mental health, <strong>an</strong>d even beyond concerns related to patients’<br />
physical health; m<strong>an</strong>y patients also come in with questions about disability<br />
benefit, housing <strong>an</strong>d so on. It should be noted that m<strong>an</strong>y of the service’s<br />
patients will present firstly to the two psychiatric nurses with complaints such<br />
as a cough or other chest complaints, rather th<strong>an</strong> to their local PHC clinic. This<br />
is simply because the service is one which is welcoming <strong>an</strong>d reassuring, it is a<br />
service with which they are familiar <strong>an</strong>d is easily <strong>an</strong>d rapidly accessible with<br />
little waiting time. The two psychiatric nurses will then refer the patient to their<br />
local PHC clinic. The only physical examination that they will carry out<br />
themselves is to measure patients’ blood pressure. Usually, they will give the<br />
patient a referral letter which will let the PHC staff know that this is a patient of<br />
theirs <strong>an</strong>d giving details of the medication which the patient receives so that<br />
PHC nurses will recognize side effects as such <strong>an</strong>d not as symptoms which in<br />
themselves require treatment.<br />
Processes<br />
The Upington clinic is open to patients from 7.30am until 1pm <strong>an</strong>d 2pm to 4pm<br />
Monday to Friday, except for the three days a month that <strong>an</strong> outreach<br />
psychiatric service is offered in Keimoes, Kakamas <strong>an</strong>d Kenhardt. Between 2pm<br />
<strong>an</strong>d 4pm, the nursing staff complete a number of duties within the clinic:<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
• Making up new files<br />
• Completing requisition forms for the supplies of drugs, syringes <strong>an</strong>d other<br />
sterile equipment, appointment cards <strong>an</strong>d new files<br />
• Topping up the drugs cupboard <strong>an</strong>d checking the records of drugs already<br />
distributed against qu<strong>an</strong>tity of drugs remaining in the cupboards<br />
• In the week before the psychiatrist’s visit, all 500 sets of medical records<br />
must be prepared with a written up prescription<br />
In addition, patients do come into the clinic for their appointments during the<br />
afternoon despite the fact that they are discouraged from doing so.<br />
On Monday afternoons, the nurses take <strong>an</strong> outreach service to:<br />
• Individual disabled patients in their homes within the Upington area<br />
• Old age homes <strong>an</strong>d nursing homes within the Upington area<br />
• Upington prison (1 st <strong>an</strong>d 3 rd Monday of each month)<br />
• House visits to assess families within their own environment<br />
• Suicide attempt counselling for patients admitted to Gordonia Hospital<br />
An appointment with a new patient will take between 1 to 11/2 hours. In this<br />
appointment, at which both nurses are present, a full medical history from birth<br />
is taken. The nurses strongly encourage patients to bring a family member<br />
with them so as to capture as much information as possible at this stage. The<br />
nurses state that they search in this initial interview for <strong>an</strong>y possible physical<br />
cause of the patient’s behaviour such as head injury or severe hyper-tension. If<br />
a physical cause is found or suggested, the nurses refer the patient back to<br />
their local PHC clinic with a letter explaining that this patient is not<br />
psychiatrically ill. On the rare occasion that a serious org<strong>an</strong>ic illness is found,<br />
patients are referred immediately to Gordonia casualty.<br />
New patients are called in for a follow up appointment one week after their<br />
initial appointment, primarily to determine whether the medication is working.<br />
Once the patient is stabilised, monthly appointments for medication take<br />
between 5 <strong>an</strong>d 10 minutes, depending on whether the patient has <strong>an</strong>y<br />
problems or complaints.<br />
A full report is written into the notes at every appointment, however cursory<br />
the patient’s visit. Patients are always asked if they have experienced <strong>an</strong>y<br />
problems over the past month <strong>an</strong>d if they feel well.<br />
L<strong>an</strong>guage<br />
Ninety percent of the nurses’ dealings with patients are in Afrika<strong>an</strong>s. They<br />
report that a h<strong>an</strong>dful of their regular patients speak only Xhosa or Tsw<strong>an</strong>a. If<br />
these patients do not bring with them a family member or neighbour who c<strong>an</strong><br />
tr<strong>an</strong>slate for them, the nurses go out into the street <strong>an</strong>d will ask the first person<br />
who c<strong>an</strong> tr<strong>an</strong>slate to do so for them. The number of patients with whom there<br />
is l<strong>an</strong>guage barrier is increasing as the numbers of seasonal workers migrating<br />
into the area from Kurum<strong>an</strong> increases each year.<br />
8
Collection <strong>an</strong>d use of Iinformation<br />
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Unlike other areas of the country, the psychiatric service in Lower Or<strong>an</strong>ge is not<br />
required to collect data regarding the diagnoses of the patients on their register<br />
or even to break down their attend<strong>an</strong>ce figures into basic categories of mental<br />
illness. For example, psychiatric outpatients clinic at Mary Theresa hospital in<br />
Mount Frere records diagnoses within their register, which allows a profile of<br />
mental illness within the region to be produced within the following basic<br />
categories:<br />
• Schizophrenia<br />
• Toxic psychosis<br />
• Depression<br />
• Senile dementia<br />
• M<strong>an</strong>ia 2<br />
Unfortunately, no such information is collected in Lower Or<strong>an</strong>ge, <strong>an</strong>d<br />
consequently, no <strong>an</strong>alysis of data is carried out to provide information which<br />
might inform the pl<strong>an</strong>ning of health services. The raw data does exist as a<br />
diagnosis within each patient record <strong>an</strong>d c<strong>an</strong> consequently be gathered by<br />
extracting the information from each of the 700 records. This exercise was<br />
carried out in October 1998; the results are given in section 3.8.<br />
Confidentiality<br />
At the start of their visits to the psychiatric nurses, patients sign a consent form<br />
with regard to the confidentiality of their records <strong>an</strong>d details. The form permits<br />
access to the records for “all the members of a multi-disciplinary team directly<br />
involved in medical care”. This facilitates communication between psychiatric<br />
service staff <strong>an</strong>d other healthcare professionals, particularly PHC nurses.<br />
Safety <strong>an</strong>d Security<br />
The two nurses aim to see all patients together, i.e. if possible, both nurses are<br />
present in the room during each <strong>an</strong>d every patient visit. This is primarily for<br />
reasons of safety. New patients are never seen by one nurse alone until their<br />
assessment is complete <strong>an</strong>d the nurses have established whether the patient<br />
has a tendency to be violent, aggressive or unpredictable.<br />
If a patient to whom the nurses are supposed to give medication is recalcitr<strong>an</strong>t,<br />
they will in the last resort call the police to pin him (occasionally her) down<br />
while <strong>an</strong> injection is given.<br />
As the nurses spend a large part of each day giving injections to potentially<br />
violent <strong>an</strong>d aggressive patients, it is perhaps not surprising that they sustain<br />
needlestick injuries fairly frequently. This obviously exposes them to the risk of<br />
infection with <strong>an</strong>y diseases carried by their patients; they report being exposed<br />
2 Jones L (1998) <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong>s in Mount Frere Sub-District, Initiative for Sub-District Support, <strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong>,<br />
Durb<strong>an</strong><br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
to the blood of patients known variously to have syphilis, drug-resist<strong>an</strong>t TB <strong>an</strong>d<br />
Hepatitis.<br />
In the event of a needlestick injury, the two nurses follow a procedure which<br />
they have created for themselves <strong>an</strong>d which is not written down. The most<br />
recent guidelines for action following exposure to blood of which they have a<br />
copy were published in 1992 <strong>an</strong>d obviously make no reference to prophylactic<br />
drugs for HIV. In fact a Northern Cape provincial protocol for post-exposure<br />
prophylaxis (PEP) was published in April 1998 <strong>an</strong>d Gordonia Hospital has a<br />
copy, but it does not appear to have filtered down to the nurses.<br />
The procedure followed by the two psychiatric nurses is as follows:<br />
1. If possible, they take a blood sample from the patient <strong>an</strong>d take it to the<br />
laboratory at Gordonia Hospital for rapid testing.<br />
2. The nurse involved receives limited (minimal) HIV pre-test counselling <strong>an</strong>d<br />
discusses the potential need to embark on a course of PEP treatment<br />
(presumably with a combination of AZT <strong>an</strong>d 3TC, although this is not clear).<br />
3. They complete a report on the incident which is given to the Chief<br />
Professional Nurse at district level with responsibility for Primary <strong>Health</strong><br />
Care.<br />
4. If the results of <strong>an</strong>y tests on the patient’s blood should be positive, the<br />
nurses commence treatment as appropriate.<br />
As the blood tests for HIV have proved negative each time, neither of the two<br />
nurses has ever had to take PEP for HIV. They have however both taken drugs<br />
following the positive patient blood tests for other diseases such as syphilis.<br />
The two nurses appear to have developed a very good working relationship<br />
with the laboratory staff at Gordonia to facilitate this arr<strong>an</strong>gement.<br />
The other area of concern with regard to the safety of both nursing staff <strong>an</strong>d<br />
patients is the lack of adequate facilities for disposal of sharps. The clinic<br />
possesses two, very small sharps bins of the sort which are intended to be<br />
thrown away intact, container included. As this is all they have, however, the<br />
two nurses simply empty their contents when full into cardboard boxes which<br />
are stored in <strong>an</strong> open room at the back of the clinic. When a number of full<br />
boxes have accumulated, the nurses take the boxes up to Gordonia Hospital for<br />
disposal.<br />
The d<strong>an</strong>ger of having a large number of used syringes accessible within the<br />
clinic is considerable, especially as the clinic’s patients are potentially <strong>an</strong>d<br />
occasionally aggressive. Although the room in which they are kept is<br />
theoretically off limits to patients, there is little to stop them w<strong>an</strong>dering into the<br />
room. This is most likely in the weeks when Mr Piotrowski, the psychiatrist, is<br />
present, when up to 80 patients together with their relatives pass through the<br />
clinic, some waiting in <strong>an</strong> additional waiting room adjacent to the store room in<br />
which the used sharps are stored.<br />
In the interests of the safety of both staff <strong>an</strong>d patients, efforts should be made<br />
to provide improved facilities for the disposal of sharps as soon as possible.<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Defaulters<br />
At the end of each month, the nurses check through the diary to establish<br />
which if <strong>an</strong>y patients have not presented for the medication during the month.<br />
Once a period of over 2 months elapses without a patient visiting, the nurses<br />
will make attempts to contact the patient or their family; to this end, they either<br />
write to the patient, or more commonly with the majority of the patients who<br />
live in or around Upington, they will visit the patient’s home. If a patient is not<br />
traced after three months, their file is moved to a separate filing cabinet for<br />
“Defaulters”, until such time as he or she may re-appear.<br />
If a patient pl<strong>an</strong>s to leave the area, the nurses will write a referral letter for the<br />
patient to take with him/her. More commonly, patients leave the area at short<br />
notice <strong>an</strong>d c<strong>an</strong>not be traced. It is quite common for the nurses to receive<br />
phone calls <strong>an</strong>d letters from psychiatric services in the rest of the country<br />
reporting on the presentation of one of their missing patients. To facilitate this<br />
communication, all patients of the psychiatric service possess <strong>an</strong> appointment<br />
card on which the phone numbers of both the Upington clinic <strong>an</strong>d the West End<br />
Hospital are given, <strong>an</strong>d this is how contact between clinics is facilitated. The<br />
card does not give details of diagnosis or medication, but simply the date of the<br />
patient’s next appointment. The cards are supplied by either West End Hospital<br />
specifically or Kimberley Hospital (non-psychiatric) <strong>an</strong>d are st<strong>an</strong>dard outpatient<br />
appointment cards. The cards are ordered every month as a st<strong>an</strong>dard<br />
requisition; the nurses report that they generally order 100 <strong>an</strong>d receive 50.<br />
2.3 Outreach Clinic <strong>Service</strong><br />
The two Sisters provide <strong>an</strong> outreach service to three local areas: Keimoes,<br />
Kakamas <strong>an</strong>d Kehardt. They travel to the these areas by car once a month <strong>an</strong>d<br />
see during this time all the patients who live in these areas for the monthly<br />
medication appointment. Numbers of patients seen at these clinics are given in<br />
Appendix 1.<br />
The monthly outreach psychiatric service offered in Keimoes, Kakamas <strong>an</strong>d<br />
Kenhardt is located within the PHC clinic in each town. It is not known how<br />
adequate facilities are in these clinics to cope with <strong>an</strong> additional outpatients<br />
service going on during normal clinic hours. There are also considerable<br />
concerns regarding patients’ confidentiality within this arr<strong>an</strong>gement, as<br />
psychiatric patients are seated within the same waiting area as all other<br />
patients but are called to a clearly distinct service.<br />
2.4 <strong>Service</strong> to outlying areas (“postal service”)<br />
Patients from other outlying areas to which the District council provides services<br />
are initially referred to the Upington clinic for diagnosis <strong>an</strong>d the first stages of<br />
care. They are treated at the Upington clinic for the first three months, after<br />
which they tr<strong>an</strong>sfer, if stable, to the care of their local PHC clinic sisters. These<br />
areas, in which there is no outreach psychiatric service, are supplied with<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
psychiatric medications by a “postal” service, by which medications are posted<br />
from Kimberley to PHC clinic nurses, who distribute these to the patients.<br />
These patients are the most likely not to keep their yearly appointment with the<br />
Psychiatrist. The usual practice is for the nurses at each PHC clinic to escort<br />
the group of patients from the area to Upington. In practice, however, the<br />
group consists primarily only of those patients who have been experiencing<br />
difficulties with medication or who have relapsed, as the journey is a long one.<br />
This results in patients being taken off the register if a period of more th<strong>an</strong> two<br />
years elapses without their having seen the psychiatrist, as it is illegal for their<br />
medications to be prescribed only by a nurse without the supervision of a<br />
psychiatrist once a year. 3<br />
It is not known how m<strong>an</strong>y patients receive their psychiatric care in this m<strong>an</strong>ner;<br />
figures would presumably be held in Kimberley.<br />
3.1 The Psychiatrist<br />
The psychiatrist to the Lower Or<strong>an</strong>ge region (in fact, to practically the whole of<br />
the Northern Cape Province) is Mr Piotrowski. He appears to spend much of his<br />
time travelling to the 51 different local clinics which fall under his jurisdiction.<br />
Within the Lower Or<strong>an</strong>ge region, he runs outpatients clinics at which he sees all<br />
the patients on the nursing service’s register. These clinics are run:<br />
• for three days at Upington, every six months<br />
• for one day each at Keimoes, Kakamas, Kenhardt, Pofadder, Boegoeberg<br />
<strong>an</strong>d Grobelershoop once a year<br />
The main purpose of these visits is firstly to see new referrals <strong>an</strong>d secondly to<br />
allow the psychiatrist to sign off <strong>an</strong>d approve the medication prescription of<br />
each patient as recommended by the psychiatric nurses. This latter task is<br />
necessary, according to all the nursing staff interviewed, because it is a legal<br />
requirement that patients taking psychiatric drugs be seen at minimum once a<br />
year by a psychiatrist; without this, ongoing nurse prescribing is illegal.<br />
Consequently, the psychiatrist sees a large number of patients in a very short<br />
time sp<strong>an</strong>; at Upington, the numbers are of necessity around 70-80 patients a<br />
day. Although it is frowned upon by Kimberley, the psychiatrist also makes<br />
visits to the old age homes within Upington, rather th<strong>an</strong> dem<strong>an</strong>d that these<br />
patients come to the clinic.<br />
Mr Piotrowski does not have a cell phone; therefore, when questions arise, the<br />
nurses waste m<strong>an</strong>y hours calling around the local clinics throughout the<br />
Northern Cape in <strong>an</strong> attempt to trace him amongst the local clinics within the<br />
locality that he is known to be visiting. Such queries however arise<br />
infrequently; only when they are uncertain with regard to the prescription of a<br />
drug for a patient who also has <strong>an</strong> existing org<strong>an</strong>ic disease do the nurses<br />
consult their psychiatrist.<br />
3 It is not clear what the source of these prescribing regulations, why this supervisory role could not be<br />
undertaken by a local doctor rather th<strong>an</strong> a psychiatrist specifically <strong>an</strong>d whether the notion of a yearly<br />
medical consultation remains the legislative basis.<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Mr Piotrowski has a Medical Officer working with him who should eventually<br />
lighten the burden upon him as <strong>an</strong> individual <strong>an</strong>d act as <strong>an</strong> alternative source of<br />
advice to the nurses. At present, however, she is very new <strong>an</strong>d is not in a<br />
position to advise the nurses as this is her first post within psychiatric medicine.<br />
2.5 Psychologist<br />
There is a private clinical psychologist within Upington but no state psychologist<br />
throughout the entire province apart from one who works solely at the West<br />
End Hospital. Nursing staff within Lower Or<strong>an</strong>ge felt this to be one of the<br />
greatest weaknesses of the service they offer.<br />
2.6 Forensic patients<br />
Forensic patients who need observation (4/5 a year) are referred out of the<br />
Province to Valkenberg, a psychiatric hospital in Cape Town. This is a legacy<br />
from the days when Valkenberg provided a service to the whole of what was<br />
then the Cape Province. There has long been talk that this will eventually<br />
ch<strong>an</strong>ge <strong>an</strong>d that forensic patients will go instead to Bloemfontein. The nurses<br />
rarely receive further information or feedback about patients who have been<br />
admitted to Valkenberg once they return to the community; indeed, they do not<br />
necessarily know that such patients have returned at all.<br />
2.7 Child <strong>an</strong>d Adolescent <strong>Mental</strong> <strong>Health</strong><br />
Both adult <strong>an</strong>d child/adolescent care is undertaken by all the providers of<br />
psychiatric care in the region; there are no dedicated acute or community<br />
psychiatric services for this client group. The provincial education department<br />
has two psychologists for school age patients but they deal primarily with less<br />
severe learning disabilities <strong>an</strong>d the education system is ill-equipped to deal with<br />
children with disruptive behavioural disorders. The provincial Department of<br />
Education reports that m<strong>an</strong>y schools simply refuse to include such children in<br />
their classes <strong>an</strong>d that their schooling often ends at this point.<br />
2.8 Elderly <strong>Mental</strong>ly Ill<br />
There are no specialist services available for this client group. Patients with<br />
senile dementia are seen by the psychiatric nurse practitioners.<br />
2.9 Learning Disability facilities<br />
Two schools for children with combined learning <strong>an</strong>d physical disabilities exist<br />
within Kimberley, but have only 45 places between them <strong>an</strong>d clearly c<strong>an</strong>not<br />
therefore provide for all the children within the entire Northern Cape Province<br />
who require such a service. In <strong>an</strong>y case, neither has provision for children to<br />
board, <strong>an</strong>d they cater therefore solely for children from Kimberley itself. Most<br />
children with learning disability from Lower Or<strong>an</strong>ge therefore remain at home<br />
<strong>an</strong>d may or may not attend school.<br />
13
2.10 Drug <strong>an</strong>d Alcohol <strong>Service</strong>s<br />
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
No state facilities for rehabilitation exist. Private hostels for subst<strong>an</strong>ce users<br />
seeking treatment are available but are outside the fin<strong>an</strong>cial capacities of most<br />
Lower Or<strong>an</strong>ge families.<br />
2.11 Crisis/emergency service<br />
The region has does not possess the capacity to provide this level of service. At<br />
present, the service is officially <strong>an</strong> “office hours only” service, although the<br />
psychiatric nurse practitioners do receive phone calls at home during the night.<br />
These calls are most frequently from the Casualty departments of the region’s<br />
hospitals, <strong>an</strong>d their purpose is generally to find out whether a patient who has<br />
arrived at Casualty <strong>an</strong>d is displaying behaviour suggesting mental illness is<br />
already a patient known to the psychiatric service <strong>an</strong>d if so, what medication<br />
they are already receiving. Such patients are usually kept overnight in hospital<br />
<strong>an</strong>d sedated until the psychiatric nurses c<strong>an</strong> visit them the next day.<br />
When known patients of the service are involved in criminal activity, the police<br />
will call the psychiatric nurses the next morning to let them know that the<br />
patient has been detained. On the occasions that a patient is so aggressive or<br />
violent overnight or during the weekend that they c<strong>an</strong>not be m<strong>an</strong>aged within<br />
the community, the family will request the police to detain them in the police<br />
cells <strong>an</strong>d the nurses will be called in to see them the next day or Monday<br />
morning. This situation is obviously far from ideal.<br />
2.12 Certification of Involuntary patients<br />
Under the 1973 <strong>Mental</strong> <strong>Health</strong> Act, patients who will not voluntarily enter<br />
inpatient psychiatric care c<strong>an</strong> be “certified” under Section 9 <strong>an</strong>d compelled to<br />
do so. A patient’s certification must be agreed by two doctors, who may not<br />
work within the same practice.<br />
This legislation is invoked only rarely within the Lower Or<strong>an</strong>ge Region, although<br />
cases do occasionally end up at the Upington magistrates court. The nurses<br />
make every attempt to stabilise the patient with the r<strong>an</strong>ge of drugs available to<br />
them in Upington <strong>an</strong>d to keep the patient within the community rather th<strong>an</strong><br />
send them to Kimberley. Should improvement however not be achieved, the<br />
only circumst<strong>an</strong>ces in which such a drastic measure is taken by the psychiatric<br />
nursing staff are:<br />
• That the patient is a serious d<strong>an</strong>ger to themselves <strong>an</strong>d is highly likely to<br />
self-harm unless under close supervision; <strong>an</strong>d, that there is no-one (such<br />
as family) able <strong>an</strong>d willing to undertake such a supervisory role<br />
• That the patient represents a real d<strong>an</strong>ger to others <strong>an</strong>d c<strong>an</strong>not be allowed<br />
to remain within the community in the interests of others’ safety<br />
The numbers of Lower Or<strong>an</strong>ge patients referred to West End, whether<br />
voluntarily or involuntarily, has reduced signific<strong>an</strong>tly over the past ten years;<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
only a h<strong>an</strong>dful of patients are now referred each year, of whom five to seven<br />
will be certified under Section 9 of the <strong>Mental</strong> <strong>Health</strong> Act. The nurses report<br />
that they now care for the vast majority of patients within the community; of<br />
those who are referred, a much lower number th<strong>an</strong> ten years ago are<br />
schizophrenic, while the number of patients with bi-polar mood disorders who<br />
need referral has increased.<br />
2.13 <strong>Health</strong> promotion/prevention activities<br />
The psychiatric nurses reported that they had made a few tentative ventures<br />
into preventative work. One was in 1995, when they participated in a “<strong>Health</strong><br />
Week”: they spoke to groups of high school pupils who were bussed into a<br />
stadium in which they received education on various aspects of health. A<br />
number of referrals had stemmed from that experience, suggesting that there<br />
was a signific<strong>an</strong>t number of teenagers for whom education was the prompting<br />
they needed to come forward with their problems. Following the <strong>Health</strong> Week,<br />
one school actually invited the psychiatric nurses directly to run a number of<br />
sessions with their pupils; however, the process was not repeated the next<br />
year. M<strong>an</strong>y nurses agreed that individual schools would not be prepared to<br />
org<strong>an</strong>ise workshops around alcohol or dagga abuse for their pupils because<br />
they feared it would reflect badly upon the school. It was felt that less attention<br />
had been given to these issues since the posts of dedicated school nurses were<br />
abolished some years ago.<br />
2.14 Inter-sectoral work<br />
Criminal justice system<br />
When patients need to appear in a criminal court as defend<strong>an</strong>ts, the two nurses<br />
c<strong>an</strong> be asked to give evidence, <strong>an</strong>d are on occasion, subpoenaed by the courts<br />
against their patient’s wishes. In such circumst<strong>an</strong>ces, they state merely that<br />
the defend<strong>an</strong>t is a patient of theirs <strong>an</strong>d that they prescribe medication for him.<br />
If a patient wishes their lawyer to have access to their medical records, they<br />
sign a form giving a named individual permission to access the records.<br />
Correctional <strong>Service</strong>s<br />
The psychiatric nurses run a clinic session within Upington Prison twice a month<br />
for around two hours at which they see between 18 <strong>an</strong>d 25 patients. As<br />
Upington prison has recently been upgraded to a maximum security prison,<br />
some of their short-term patients have been tr<strong>an</strong>sferred to Springbok <strong>an</strong>d<br />
Kimberley, <strong>an</strong>d a new group of inmates requiring psychiatric treatment has<br />
arrived.<br />
Welfare Department<br />
The psychiatric nurse practitioners have frequent dealings with the social<br />
workers, to whom they refer m<strong>an</strong>y of their patients. This is most commonly<br />
15
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
with regard to housing <strong>an</strong>d to disability benefits; however, they report that<br />
almost all of their patients face signific<strong>an</strong>t socio-economic problems. They are<br />
also involved in their patients’ applications for Disability Gr<strong>an</strong>t. Initial<br />
applications must be signed by the psychiatrist, but further applications for<br />
continuation of the gr<strong>an</strong>t may be signed by a Psychiatric nurse. The two<br />
Upington nurses are not aware of <strong>an</strong>y national or district policy regarding the<br />
“level” of illness which qualifies someone to receive Disability Gr<strong>an</strong>t; they follow<br />
the guidelines used by Mr Piotrowski, which are that a patient should have been<br />
on medication for six months <strong>an</strong>d still not be in a position to return to work. If<br />
this policy differs from that used by other healthcare professionals within Lower<br />
Or<strong>an</strong>ge, it may be necessary to bring some consistency of approach to the<br />
issue.<br />
2.15 Other community structures<br />
Traditional Healers<br />
A review of mental health services in the Mount Frere area highlighted the role<br />
that alternative <strong>an</strong>d traditional healers played in the community’s response to<br />
mental health difficulties <strong>an</strong>d argued that collaboration with traditional healers<br />
is <strong>an</strong> essential step in ensuring that patients requiring mental health care are<br />
brought to the psychiatric services.<br />
This <strong>an</strong>alysis appears to hold true for the Lower Or<strong>an</strong>ge area; however, given<br />
the large coloured population of the district, the forms of traditional healers to<br />
whom the community turns are very different from those in the Mount Frere<br />
region.<br />
M<strong>an</strong>y coloured families take their relatives to the “smeer-ouma” or to other<br />
traditional healers before accepting a referral to Western-style health facilities.<br />
The psychiatric nurses recalled <strong>an</strong> occasion on which one smeer-ouma had<br />
actually accomp<strong>an</strong>ied a wom<strong>an</strong> to the psychiatric clinic herself in order to<br />
ensure that she made it to the nurses. The traditional healers used by the<br />
black communities however often prescribe remedies to patients, certain of<br />
which made psychiatric illnesses much worse. In addition, the problems of a<br />
par<strong>an</strong>oid <strong>an</strong>d delusional patient were generally exacerbated by traditional<br />
healers who told them that their illness was the result of a spell cast upon<br />
them.<br />
Churches<br />
Within the district, certain church ministers pose <strong>an</strong> influential obstacle to the<br />
service. The psychiatric nurses report that m<strong>an</strong>y patients will first go to a<br />
church minister before accessing official health services. In such situations,<br />
some of the ministers have counselled patients that their distress arises from a<br />
lack of faith <strong>an</strong>d have advocated a return to God as the only remedy. To this<br />
end, patients are frequently encouraged to stop taking their medication <strong>an</strong>d<br />
m<strong>an</strong>y will do so.<br />
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Chapter 3<br />
Key Issues <strong>an</strong>d Problems<br />
3.1 Prescribing<br />
The situation with regard to prescribing of psychiatric medication appears to be<br />
fairly confused.<br />
The two psychiatric nurses administer vast qu<strong>an</strong>tities of psychiatric medication<br />
on a daily basis. After initial interview <strong>an</strong>d diagnosis, it is they who make<br />
decisions about what medications should be used <strong>an</strong>d commence treatment.<br />
Their prescriptions are then posted off to Kimberley for approval. These<br />
prescriptions, however, are for a maximum of six months. This represents a<br />
ch<strong>an</strong>ge in practice, insofar as until recently, they were only allowed to prescribe<br />
(without a doctor’s involvement) for a maximum of three months. This however<br />
was in the period when the psychiatrist visited the region on a quarterly basis.<br />
When the psychiatrist’s visits were reduced to a six monthly pattern, the nurses<br />
were told that they may prescribe for up to six months, i.e. until the next<br />
psychiatrist’s visit. These directions came from the Laura J<strong>an</strong>tjies, then Chief<br />
Professional Nurse at West End <strong>an</strong>d now the m<strong>an</strong>ager of the provincial mental<br />
health programme.<br />
Private doctors also prescribe psychiatric drugs to patients, before or during<br />
their care through the state psychiatric service. Additionally, private doctors<br />
play a role in the certification of patients when necessary.<br />
It is not clear why, if patients c<strong>an</strong> be prescribed psychiatric medication by<br />
private family practitioners without the supervision of a psychiatrist, it is<br />
necessary for a psychiatrist (rather th<strong>an</strong> <strong>an</strong>y of the local doctors) to oversee the<br />
nurses’ prescribing practice once a year. Due to the large numbers of patients<br />
involved, consultations with Mr Piotrowski c<strong>an</strong> generally only be five,<br />
occasionally ten minutes long. This appears to be <strong>an</strong> inefficient usage of skills<br />
<strong>an</strong>d expertise.<br />
There is a further issue around the capacity for nurse prescribing of psychiatric<br />
medications. M<strong>an</strong>y of the PHC nurses who participated in the focus group had<br />
completed a psychiatric placement as part of their basic training. However,<br />
because they are not currently in a specialist psychiatric post, they are unable<br />
to care in <strong>an</strong>y way for patients who have a psychiatric disorder. Amongst the<br />
group of PHC nurses, there was considerable <strong>an</strong>ger that their skills were<br />
unused <strong>an</strong>d their training wasted – a feeling shared by PHC nurses <strong>an</strong>d nursing<br />
staff from the community hospitals.<br />
The nurses stated that they find it extremely frustrating to be unable to<br />
diagnose or prescribe when the illness is psychiatric, despite the fact that they<br />
could m<strong>an</strong>age the psychiatrically ill patient just as well as they could m<strong>an</strong>age all<br />
other patients. Particularly in emergency situations, with violent or suicidal<br />
patients, nurses trained in psychiatry find it farcical, if not tragic, that they are<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
unable to prescribe even the most common tr<strong>an</strong>squillisers. Instead they must<br />
wait for the psychiatric nurse practitioners or a local GP to arrive at the scene,<br />
which may easily be 24 hours later.<br />
It is worth noting that PHC clinics do not store Schedule 5 psychiatric drugs<br />
within their drugs store, which eliminates m<strong>an</strong>y drugs such as tr<strong>an</strong>quillisers<br />
which may be needed for emergency patients in <strong>an</strong> acute phase of illness.<br />
3.2 Relations with other district healthcare providers<br />
One consequence of the fragmentation of services which characterised health<br />
services in the past was poor communication <strong>an</strong>d working relationships<br />
between different health care providers. In the case of psychiatric services,<br />
however, this problem was exacerbated by the traditional stigmatisation <strong>an</strong>d<br />
segregation of psychiatric services <strong>an</strong>d patients. This remains <strong>an</strong> ongoing<br />
problem for the psychiatric service which affects their dealings with other<br />
healthcare providers such as the local hospital, the GPs <strong>an</strong>d PHC staff. Such<br />
poor inter-relationships constitute a poor basis on which to attempt integration<br />
of psychiatric services into the wider district health system. The nature of the<br />
working relationships within Lower Or<strong>an</strong>ge are examined below.<br />
Referrals from <strong>an</strong>d to PHC<br />
The psychiatric nurses frequently refer patients to PHC clinics, as described<br />
above. They tell all their patients early on in treatment that whenever they<br />
attend a PHC clinic, they should take with them <strong>an</strong>y medications which they are<br />
taking at home in order to avoid confusion. This system appears to fall down<br />
with patients who receive their medication in injectable form.<br />
Patients are often referred to the psychiatric clinic without a letter, but are<br />
simply told by PHC nurses where the clinic is <strong>an</strong>d are told to present themselves<br />
to the nurses. Some of the letters which accomp<strong>an</strong>y patients from PHC clinics<br />
give little or no history <strong>an</strong>d are inappropriately phrased.<br />
Epileptics<br />
Despite the fact that epilepsy is not a mental illness, studies of mental health<br />
services in other areas of the country have found that the psychiatric service is<br />
expected to provide long-term care for epileptic patients. In the Lower Or<strong>an</strong>ge<br />
region, epileptics were under the care of the psychiatric service until 1988,<br />
when they were gradually tr<strong>an</strong>sferred into the care of the district surgeon;<br />
these days, the aim of the psychiatric service is to tr<strong>an</strong>sfer patients with<br />
epilepsy into the care of their local PHC team as soon as their epilepsy <strong>an</strong>d<br />
subsequent hallucinoses are controlled. This generally me<strong>an</strong>s that epileptics<br />
remain under the care of the psychiatric service only for two or three months.<br />
The only exceptions to this rule are three epileptic patients whose care is<br />
unusually complex as a cocktail of four or five different drugs are necessary to<br />
control their epilepsy.<br />
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The psychiatric nurses feel that there is however <strong>an</strong> inadequate level of<br />
underst<strong>an</strong>ding of the nature of epilepsy <strong>an</strong>d the m<strong>an</strong>agement of the epileptic<br />
patient amongst PHC staff; in each individual case, they have given detailed<br />
instructions for the care of the patient to the local PHC staff concerned.<br />
Despite such efforts to educate PHC staff, however, new patients displaying the<br />
same set of symptoms are still referred to the psychiatric service.<br />
Inappropriate referrals<br />
The psychiatric nurses perceive that there is a lack of willingness amongst PHC<br />
staff to care for patients with mental health problems, <strong>an</strong>d they feel too that<br />
PHC staff frequently attempt to “pass the buck”, i.e. to refer patients who<br />
display <strong>an</strong>y str<strong>an</strong>ge behaviour whether or not they are psychiatrically ill. In<br />
m<strong>an</strong>y such cases, patients are actually suffering from <strong>an</strong> org<strong>an</strong>ic illness which is<br />
causing their confusion or delirium.<br />
The following two cases studies are based on patients who have been referred<br />
to the psychiatric clinic in recent years <strong>an</strong>d are illustrative of the m<strong>an</strong>y similar<br />
stories which the nurses have to tell:<br />
Case Study<br />
A m<strong>an</strong> arrived at the psychiatric clinic with a referral letter from the PHC clinic<br />
where he had presented the previous day. The referral letter said that the m<strong>an</strong><br />
was very disturbed <strong>an</strong>d aggressive <strong>an</strong>d he needed to see a psychiatrist. As part<br />
of their initial interview, the psychiatric nurses measured the patient’s blood<br />
pressure, which they discovered to be 210 over 100. On discovering such<br />
severe hyper-tension, the psychiatric nurses referred him directly to Gordonia<br />
casualty. They did not open a file for him as there was nothing to suggest that<br />
he was mentally ill.<br />
Case Study<br />
A young wom<strong>an</strong> of around eighteen years of age was referred to the psychiatric<br />
clinic. Her family were complaining that she was displaying very str<strong>an</strong>ge<br />
behaviours which had started very suddenly <strong>an</strong>d unpredictably. The family had<br />
been initially to their local PHC clinic, who had seen the girl <strong>an</strong>d then referred<br />
them to the psychiatric clinic. The psychiatric nurses took a full medical history<br />
<strong>an</strong>d established that the girl displayed all the classic symptoms of diabetes.<br />
When pressed, the girl also admitted that she often woke up with bruises to her<br />
head <strong>an</strong>d legs of which she knew no cause. The nurses referred the family<br />
back to the PHC clinic, asking for investigations into a potential diagnosis of<br />
diabetes <strong>an</strong>d epileptic fits to be done. This diagnosis was confirmed <strong>an</strong>d the<br />
girl was not added to the register of psychiatric patients.<br />
The feeling of those involved with provision of the psychiatric service is that<br />
patients displaying <strong>an</strong>y str<strong>an</strong>ge behaviours at all are immediately <strong>an</strong>d often<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
inappropriately referred to their service without the basic necessary<br />
investigations being carried out first to eliminate <strong>an</strong>y alternative diagnoses. This<br />
stems partly from the PHC staff being overwhelmed with patients, but also from<br />
<strong>an</strong> approach which separates mental health problems into <strong>an</strong> altogether<br />
separate category <strong>an</strong>d denies patients with <strong>an</strong>y behavioural problems the right<br />
to initial treatment equal to that received by all other patients.<br />
Moreover, the nurses perceive that once a patient is established to have<br />
psychiatric illness <strong>an</strong>d is under the care of the psychiatric service, their care in<br />
all regards becomes the concern only of that clinic <strong>an</strong>d not of the<br />
comprehensive medical service. In Sister Muller’s words, “Once she becomes<br />
my patient, she becomes the psychiatric clinic’s problem <strong>an</strong>d not everyone<br />
else’s”.<br />
This suggestion that PHC nurses do not w<strong>an</strong>t to take <strong>an</strong>y<br />
responsibility for psychiatric patients is not borne out by discussions<br />
with them. On the contrary, m<strong>an</strong>y PHC nurses expressed a strong<br />
desire to utilise their psychiatric training <strong>an</strong>d take on the care of<br />
psychiatric patients. What prevents them from doing so is the lack of<br />
integration of services <strong>an</strong>d the restrictive legislative framework which<br />
prevents PHC nurses from prescribing psychiatric medications.<br />
It was however readily acknowledged by PHC nurses that m<strong>an</strong>y of them <strong>an</strong>d<br />
their colleagues had not completed <strong>an</strong>y psychiatric training <strong>an</strong>d that there may<br />
therefore be difficulties at PHC level in identifying psychiatric problems <strong>an</strong>d in<br />
distinguishing them from str<strong>an</strong>ge behaviours caused by other factors.<br />
The discussions around this issue <strong>an</strong>d the very different perceptions of the<br />
problem by different parties strongly suggests a need for training <strong>an</strong>d for<br />
bringing all the stakeholders within mental health services together so that<br />
some underst<strong>an</strong>ding of others’ perspectives c<strong>an</strong> be developed.<br />
Private doctors<br />
The nurses report some difficulties in working relations between themselves<br />
<strong>an</strong>d some (but not all) of the local family practitioners. They feel that some<br />
doctors have little respect for their expertise <strong>an</strong>d resent the fact that the nurses<br />
are able to prescribe.<br />
The nurses perceive in the doctors a lack of underst<strong>an</strong>ding of developments in<br />
mental health over the years since they trained <strong>an</strong>d a (potentially consequent)<br />
tendency to mis-diagnose. They report that almost all patients who have seen<br />
a doctor will be diagnosed as schizophrenic, whereas schizophrenics make up<br />
only a small percentage of their own diagnoses of the same patients.<br />
Moreover, they report too that almost all patients will have been prescribed a<br />
28 day dose of Moducate (a Fluphenazine dek<strong>an</strong>ate drug used in the treatment<br />
of schizophrenia) by the private doctors, despite the fact that this is in fact<br />
contra-indicated for patients with org<strong>an</strong>ic disorders. Most commonly, a patient<br />
with alcohol-induced delirium will be mistakenly diagnosed <strong>an</strong>d treated as<br />
psychotic. Such <strong>an</strong> error is unnecessarily damaging <strong>an</strong>d moreover will delay<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
the onset of more appropriate treatment as the nurses c<strong>an</strong>not prescribe<br />
<strong>an</strong>other psychiatric drug for 28 days until the first drug is out of the body.<br />
Finally, the psychiatric nurses believe that the local GPs do much to maintain<br />
the stigmatisation of mental illness. They cite one particular letter from <strong>an</strong><br />
Upington family practitioner which simply say “Go see the head doctor”.<br />
3.3 Lack of District Inpatient Facilities<br />
The lack of a inpatient facility within the district is a prime weakness of the<br />
service, curtailing the options for treatment. In particular, there is no capacity<br />
for short-term admissions aimed at observation <strong>an</strong>d stabilisation. Because of<br />
the dist<strong>an</strong>ce of Kimberley, admission is a last resort. The dist<strong>an</strong>ce of the<br />
hospital also makes it inappropriate for the gradual re-integration of patients<br />
into their communities, making family visits impossible <strong>an</strong>d thus cutting the<br />
patient off from their social networks <strong>an</strong>d support.<br />
In addition, there are m<strong>an</strong>y practical <strong>an</strong>d logistical problems with the operation<br />
of the referral system to West End from Lower Or<strong>an</strong>ge. One arises with regard<br />
to homeless patients: the West End Hospital will not accept a patient unless<br />
he/she has a return address. This me<strong>an</strong>s that “drifters”, with no fixed address<br />
c<strong>an</strong>not be referred to Kimberley however severe their condition.<br />
Tr<strong>an</strong>sport<br />
Tr<strong>an</strong>sport of patients to the West End Hospital is a difficult issue <strong>an</strong>d a priority<br />
for attention. There is a long-running dispute between the police <strong>an</strong>d the<br />
ambul<strong>an</strong>ce service regarding whose responsibility it is to tr<strong>an</strong>sport psychiatric<br />
patients. The only “ambul<strong>an</strong>ce service” to Kimberley is a communal minibustaxi<br />
which tr<strong>an</strong>sports all patients requiring a referral once a week. For this<br />
service to tr<strong>an</strong>sport the certified patients presents problems both of timing <strong>an</strong>d<br />
of suitability/safety. The health department therefore maintains that it is the<br />
responsibility of the police service to tr<strong>an</strong>sport the patients.<br />
However, at present certified patients travel to West End in the communal minibus<br />
despite the fact that this makes the journey just once a week. In the<br />
intervening period, patients are usually held by the police. If there is <strong>an</strong>y<br />
possibility of doing so, the psychiatric nurses will generally postpone having a<br />
patient certified until the day before the ambul<strong>an</strong>ce is due, so as to minimise<br />
the length of time that a patient must be held in a police cell or sedated in<br />
hospital.<br />
Obviously, placing highly suicidal or violent patients in <strong>an</strong> ambul<strong>an</strong>ce with other<br />
patients for a gruelling 4-5 hour journey is far from ideal; in this situation,<br />
psychiatric patients on their way to West End are heavily sedated by the<br />
psychiatric nurses before the journey.<br />
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3.4 The lack of information<br />
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
One major factor which hampers the service is the lack of available data. This<br />
me<strong>an</strong>s that there is little ability to monitor <strong>an</strong>d evaluate the perform<strong>an</strong>ce of the<br />
service. It also me<strong>an</strong>s that there is no data about the profile of the patient<br />
population, or prevalence rates within the district which would provide a basis<br />
for targeting <strong>an</strong>d pl<strong>an</strong>ning of the service.<br />
For the purposes of this study, <strong>an</strong>alysis of each of the 514 patient records held<br />
within the Upington clinic was carried out in order to develop a picture of the<br />
nature of the mental health problems of patients presenting to the clinic. The<br />
breakdown of the diagnoses of the patients, using the categories <strong>an</strong>d<br />
terminology within use at the clinic, is as follows:<br />
Number<br />
of males<br />
Number<br />
of<br />
% total<br />
male<br />
% total<br />
female<br />
Total<br />
number<br />
% Total<br />
patients<br />
Females<br />
of<br />
patients<br />
Affective 33 103 12% 43% 136 27%<br />
disorders<br />
Schizophrenia 112 77 41% 32% 189 37%<br />
Org<strong>an</strong>ic 85 39 31% 16% 124 24%<br />
Disorders<br />
Personality 3 2 1% 1% 5 1%<br />
Disorders<br />
Alcohol/ 21 7 8% 3% 28 5%<br />
dagga abuserelated<br />
disorders<br />
<strong>Mental</strong> 19 13 7% 5% 32 6%<br />
Retardation<br />
Total 273 241 100% 100% 514 100%<br />
It would be valuable to compare these figures with <strong>an</strong>y national figures for the<br />
incidence of mental illness within the population. Such a comparison could be<br />
used as the basis for local service pl<strong>an</strong>ning <strong>an</strong>d prioritisation.<br />
In two particular areas the lack of information is <strong>an</strong> acute problem. Firstly,<br />
there is <strong>an</strong> urgent need for data which would indicate the extent of subst<strong>an</strong>cemisuse<br />
within the district. Secondly, the rate of suicide is not known, although<br />
it is commonly taken as a prime marker for the incidence of mental ill-health<br />
<strong>an</strong>d also as a key indicator of the perform<strong>an</strong>ce of a mental health service.<br />
Subst<strong>an</strong>ce-related illnesses<br />
Given that the local agricultural economy is based on production of alcohol, one<br />
might expect the incidence of alcohol-related illness to be high. Indeed, the<br />
psychiatric nurse practitioners report that the area has a high incidence of<br />
senile dementia in the under 50s which clearly arises as a consequence of<br />
alcohol abuse. This claim is not subst<strong>an</strong>tiated by the figures above, but this<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
discrep<strong>an</strong>cy may arise due to patients being categorised within a broader<br />
definition of their illness. All nurses involved in the study reported that they see<br />
m<strong>an</strong>y patients who suffer from the long-term effects of alcohol abuse, such as<br />
chronic hallucinations, even after they have stopped drinking alcohol. In<br />
addition, during the period of withdrawal from alcohol, epileptic-type fits <strong>an</strong>d<br />
mental health problems are common.<br />
Dagga-related problems are also widely mentioned as a cause for concern <strong>an</strong>d<br />
some shock was expressed at the young age at which children evidently begin<br />
using it (as young as twelve years old).<br />
Research is urgently needed to establish the extent of subst<strong>an</strong>ce abuse so as to<br />
allow for services to be pl<strong>an</strong>ned <strong>an</strong>d targeted appropriately. This is in line with<br />
national policy which has directed that subst<strong>an</strong>ce-abuse services should be a<br />
national priority.<br />
Suicide<br />
The psychiatric nurses report that they are called into Gordonia Hospital on<br />
average two or three times a week to attend to attempted suicide patients, who<br />
are normally aged between sixteen <strong>an</strong>d thirty. A signific<strong>an</strong>t number of patients<br />
will never end up in Gordonia as they will successfully take their lives.<br />
Signific<strong>an</strong>tly, most of the attempted suicide patients were not known to the<br />
service beforeh<strong>an</strong>d. However, both Gordonia casualty staff <strong>an</strong>d the psychiatric<br />
staff concur that the majority of the patients who attempt suicide have no<br />
psychiatric illness <strong>an</strong>d are triggered solely by specific events rather th<strong>an</strong><br />
delusion or depression.<br />
In addition, the PHC nurses participating in the focus group identified suicide,<br />
particularly teenage suicide, as one of the major mental health issues that they<br />
regularly faced. They too suggested that the suicide figures do not correlate<br />
with the actual prevalence of psychiatric illness. However, a broad concept of<br />
mental health must surely attempt to tackle all attempted suicides <strong>an</strong>d to the<br />
causes of such attempts, particularly unpl<strong>an</strong>ned pregn<strong>an</strong>cy.<br />
Neither the psychiatric nurses nor the DMT are aware of the actual suicide rate<br />
for the region; this may perhaps be established through the Provincial<br />
Department of <strong>Health</strong> or the Home Affairs Department, but it may be that the<br />
information is not collated as such by <strong>an</strong>y authority. If the true rate c<strong>an</strong> be<br />
extrapolated from the figures at Gordonia Hospital, this would be a worryingly<br />
high level. Consequently, the need to establish the suicide rate is <strong>an</strong> urgent<br />
one.<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Chapter 4<br />
Integration of <strong>Mental</strong> <strong>Health</strong> into PHC<br />
4.1 National <strong>an</strong>d Local Context<br />
The 1995 White Paper, Tr<strong>an</strong>sformation of the <strong>Health</strong> System, outlined the way<br />
forward for the development of mental health services in South Africa. The two<br />
following principles of development are set out:<br />
(1) A comprehensive <strong>an</strong>d community-based mental health service<br />
(including subst<strong>an</strong>ce abuse prevention <strong>an</strong>d m<strong>an</strong>agement)<br />
should be pl<strong>an</strong>ned <strong>an</strong>d co-ordinated at the national, provincial,<br />
district <strong>an</strong>d community levels <strong>an</strong>d <strong>integrated</strong> with other health<br />
services.<br />
(2) Hum<strong>an</strong> resource development for mental health services should<br />
ensure that personnel at various levels are adequately trained<br />
to provide comprehensive <strong>an</strong>d <strong>integrated</strong> mental health care<br />
based on primary health care principles.<br />
The implementation of these principles within the Lower Or<strong>an</strong>ge/Northern Cape<br />
scenario over the coming months presents a great challenge. The psychiatric<br />
service at present lacks the comprehensive approach a primary health care<br />
philosophy suggests; is overwhelmingly curative in approach <strong>an</strong>d is<br />
fundamentally distinct in its delivery from other services rendered at community<br />
level.<br />
On the other h<strong>an</strong>d, Lower Or<strong>an</strong>ge is lucky to possess a sound <strong>an</strong>d wellestablished<br />
service, <strong>an</strong>d staff in whom those patients on the psychiatric register<br />
clearly have a great deal of confidence. The expertise <strong>an</strong>d experience of Sister<br />
Muller <strong>an</strong>d Sister Diergaart will be of immense value throughout the training<br />
<strong>an</strong>d preparation which will take place to facilitate successful integration of the<br />
service.<br />
In addition, <strong>an</strong>d no less crucially, this study found that health professionals<br />
across PHC services within Lower Or<strong>an</strong>ge are extremely positive about the<br />
concept of integrating mental health services into PHC <strong>an</strong>d fully support the<br />
thinking behind the move. It is on this strength of feeling that training <strong>an</strong>d<br />
preparation must build in the next few months. Developing the hum<strong>an</strong><br />
resource capacity to deliver a district/community level curative <strong>an</strong>d<br />
rehabilitative service will be no small task; issues both of clinical skills <strong>an</strong>d<br />
knowledge, <strong>an</strong>d also of time, will need to be addressed.<br />
Finally, it is positive to note that a wealth of ideas exists amongst both<br />
psychiatric <strong>an</strong>d PHC staff regarding the priorities for preventative services,<br />
especially with regard to subst<strong>an</strong>ce abuse prevention <strong>an</strong>d m<strong>an</strong>agement. There<br />
is clear agreement at grassroots level with the national prioritisation of<br />
subst<strong>an</strong>ce misuse services. The tr<strong>an</strong>sfer of the care of stable psychiatric<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
patients into PHC presents the district with a rare opportunity to tr<strong>an</strong>sfer staff<br />
from curative to preventative work. A tr<strong>an</strong>sfer of this sort would be very much<br />
in line with national policy <strong>an</strong>d yet also fulfil pressing local needs.<br />
However, preparation for integration must acknowledge that there are very<br />
strong fears about what ch<strong>an</strong>ge might me<strong>an</strong> for individuals <strong>an</strong>d their jobs. The<br />
psychiatric nurses are extremely concerned that they will be tr<strong>an</strong>sferred into<br />
generalist PHC roles for which they are unprepared <strong>an</strong>d which would not make<br />
use of the expertise they have developed over m<strong>an</strong>y years. This fear is based<br />
on the experiences of psychiatric nurses in areas such as the Western Cape<br />
where m<strong>an</strong>y psychiatric nurses have been forced into undertaking increasing<br />
amounts of generalist work.<br />
For their part, the PHC nurses fear that they will be expected to take on a role<br />
for which they are unprepared <strong>an</strong>d about which they have little confidence.<br />
Furthermore, they are concerned about the additional work which ch<strong>an</strong>ge will<br />
bring <strong>an</strong>d their physical capacity to cope with <strong>an</strong> additional <strong>an</strong>d complex<br />
workload within the clinics. Training <strong>an</strong>d preparation for ch<strong>an</strong>ge must directly<br />
address these fears.<br />
Finally, embarking on the process of ch<strong>an</strong>ge should not happen in a vacuum.<br />
Integration of psychiatric services into PHC has already been attempted in<br />
various provinces <strong>an</strong>d districts of South Africa, with varying degrees of success<br />
<strong>an</strong>d these lessons should be taken on board by the Lower Or<strong>an</strong>ge DMT.<br />
Analysing developments in KwaZulu-Natal, Peterson 4 suggests that there is a<br />
d<strong>an</strong>ger that integration into a generalist curative context results in the loss of<br />
the holistic patient approach <strong>an</strong>d the special therapeutic relationship that<br />
develops between psychiatric nurse <strong>an</strong>d patient. She also makes three practical<br />
recommendations for district integration: firstly, that specialist psychiatric<br />
nurses in their new role work to <strong>an</strong> agreed, written <strong>an</strong>d visible job description;<br />
secondly, that psychotropic drugs become part of the primary care essential<br />
drug list; <strong>an</strong>d thirdly, that resources tr<strong>an</strong>sferred from provincial to district<br />
budgets to facilitate integration initially be ringfenced within district budgets so<br />
as to ensure that mental health retains its current levels of funding.<br />
Working within the Western Cape, Muller 5 makes similar observations about the<br />
effect of integration upon the funding of psychiatric services. She warns that<br />
the subordinate status of mental health leads to its low prioritisation by district<br />
m<strong>an</strong>agement teams <strong>an</strong>d that consequently, integration into the district often<br />
implies a loss of resources. This applies not only to fin<strong>an</strong>cial resources, but also<br />
to hum<strong>an</strong> resources: she observes that becoming a part of the primary health<br />
care team too often me<strong>an</strong>s the loss of time dedicated to mental health work<br />
specifically.<br />
4 Peterson, I. (1998), Org<strong>an</strong>isational Barriers to Comprehensive Integrated Primary <strong>Mental</strong> <strong>Health</strong> Care,<br />
Department of Psychology, University of Durb<strong>an</strong>-Westville, work in progress<br />
5 Muller L. et al (1998), <strong>Mental</strong> <strong>Health</strong> Integration at the District Level in the Western Cape, Department<br />
of Psychiatry, University of the Western Cape, work in progress<br />
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The lessons that c<strong>an</strong> be drawn out of the experiences of both KwaZulu-Natal<br />
<strong>an</strong>d the Western Cape provinces are worth considering as the pl<strong>an</strong>ning process<br />
gets underway in Lower Or<strong>an</strong>ge.<br />
4.2 First Steps<br />
The immediate need is for a clear vision of what “integration” actually me<strong>an</strong>s to<br />
be developed <strong>an</strong>d shared by all involved. What is abund<strong>an</strong>tly clear from<br />
discussions with key roleplayers is that no notion of how services will in future<br />
be delivered is yet shared. On the contrary, it seems that there are signific<strong>an</strong>tly<br />
different notions of how far the service will be reconfigured. This reflects<br />
Muller’s finding in the Western Cape that even after the process of ch<strong>an</strong>ge has<br />
been underway for some years, there is no one agreed notion of what “<strong>an</strong><br />
<strong>integrated</strong> service” will look like. 6 In order to avoid such confusion in Lower<br />
Or<strong>an</strong>ge, the vision must be established before <strong>an</strong>y ch<strong>an</strong>ge process actually<br />
begins.<br />
The basic question concerns how far curative services will be tr<strong>an</strong>sferred into<br />
the community. Amongst key roleplayers, two major future visions of the<br />
future appear to exist:<br />
(A)<br />
(B)<br />
M<strong>an</strong>agement of all psychiatric patients is tr<strong>an</strong>sferred to PHC clinics which<br />
would then have direct referral rights to the West End hospital if a<br />
specialist psychiatric service was needed<br />
M<strong>an</strong>agement of all stable patients is tr<strong>an</strong>sferred to PHC level; a more<br />
specialist psychiatric service is maintained to take referrals from PHC<br />
level of new or relapsed patients <strong>an</strong>d to supervise PHC clinic staff.<br />
Which of these options is chosen as the future vision of services c<strong>an</strong> only be the<br />
decision of the district m<strong>an</strong>agement team together with relev<strong>an</strong>t staff. It<br />
should however be a decision made as soon as possible <strong>an</strong>d in consultation<br />
with ideally with representatives of the wider community.<br />
Local developments should however reflect the nationally prescribed framework<br />
for the development of local mental health services. The national guid<strong>an</strong>ce<br />
argues that districts should maintain their own specialist psychiatric<br />
services <strong>an</strong>d that PHC staff c<strong>an</strong>not be expected to m<strong>an</strong>age new or<br />
relapsed patients on their own. For this reason, the recommendation<br />
of this paper is that option B is adopted as the future model of<br />
services. Within Lower Or<strong>an</strong>ge, this would constitute a similar role to<br />
that now taken by the District TB co-ordinator.<br />
In order to help Lower Or<strong>an</strong>ge decide how best to adapt their own services, the<br />
specifics of the nationally prescribed framework as laid out in the White Paper<br />
are outlined below.<br />
6 ibid.<br />
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4.3 The role of the district<br />
The White Paper lays out the direct responsibilities of the district in provision of<br />
mental health services as follows:<br />
“At district level, the health authorities will ensure the comprehensive<br />
integration of mental health services with other services. Pl<strong>an</strong>ning of mental<br />
health services should be undertaken, with the active participation of various<br />
stakeholders, especially the communities.<br />
i. Providing mental health <strong>an</strong>d subst<strong>an</strong>ce abuse prevention, promotion <strong>an</strong>d<br />
rehabilitative services, giving special attention to the pl<strong>an</strong>ning,<br />
implementation <strong>an</strong>d co-ordination of community-based rehabilitation<br />
ii. Pl<strong>an</strong>ning <strong>an</strong>d implementing inpatient <strong>an</strong>d day-patient care for the<br />
mentally-ill <strong>an</strong>d subst<strong>an</strong>ce abusers, establishing a 24 hour consultation<br />
service for mentally ill patients <strong>an</strong>d victims of subst<strong>an</strong>ce abuse<br />
iii. Provide training for health facility staff<br />
iv. Undertake mental health education programmes in communities<br />
v. Establish <strong>an</strong>d maintain mental health committees <strong>an</strong>d maintain<br />
collaboration with other sectors, private practitioners, traditional healers<br />
<strong>an</strong>d NGOs<br />
vi. Provide emergency <strong>an</strong>d crisis intervention services<br />
vii. Collect data, initiate <strong>an</strong>d contract out research in accord<strong>an</strong>ce with local<br />
needs, with the support of relev<strong>an</strong>t institutions<br />
viii. Develop appropriate indicators for monitoring <strong>an</strong>d evaluation<br />
It is import<strong>an</strong>t that data collection, <strong>an</strong>alysis <strong>an</strong>d result<strong>an</strong>t action be performed<br />
at each level <strong>an</strong>d appropriate feedback given , especially to the communities”.<br />
What needs to be done within Lower Or<strong>an</strong>ge to implement this pl<strong>an</strong>?<br />
Clearly, there is a huge gap between the service which Lower Or<strong>an</strong>ge currently<br />
offers <strong>an</strong>d the vision of district service suggested in this list. It would be<br />
unrealistic to aim to develop a service along these lines in <strong>an</strong>ything except the<br />
very long term, given the external constraints at national <strong>an</strong>d provincial level.<br />
However, the list does provide a framework around which to pl<strong>an</strong> the<br />
decentralisation of Lower Or<strong>an</strong>ge’s services. Essentially, the list above<br />
describes five main functions. The development of each function is discussed in<br />
more detail below:<br />
1. Specialist service provision<br />
2. Pl<strong>an</strong>ning of services<br />
3. Training of staff<br />
4. Prevention <strong>an</strong>d promotion work<br />
5. Intersectoral liaison<br />
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1. Specialist <strong>Service</strong>s provision<br />
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Lower Or<strong>an</strong>ge lacks m<strong>an</strong>y of the more complex services which the White Paper<br />
delineates as district level services. However, the tr<strong>an</strong>sfer of stable patients<br />
should free up time of specialist staff such that they are able to develop this<br />
new role.<br />
Of the specialist services outlined, the most pressing local need in the eyes of<br />
healthcare staff is for alternative therapies to be available, particularly<br />
counselling <strong>an</strong>d a state psychologist. The White Paper recommends that the<br />
skills of all specialist mental health staff be upgraded to include counselling<br />
skills <strong>an</strong>d the relev<strong>an</strong>t staff appear to be keen to undertake such training.<br />
The other option in terms of developing specialised services is to take up the<br />
issue of the usage of Mr Piotrowski’s time. If one of the doctors from Gordonia,<br />
or one of the GPs, could fulfil the role of giving yearly approval to the five<br />
hundred prescriptions, the six days a year that Mr Piotrowski spends in<br />
Upington could perhaps be used to deliver more specialist services such as<br />
psychotherapy, depending of course on Mr Piotrowski’s specialisms.<br />
Alternatively, the district could negotiate with the Provincial office <strong>an</strong>d replace a<br />
proportion of Mr Piotrowski’s visits with visits by one of the Kimberley<br />
psychologists. These will not be simple discussions but should nevertheless<br />
taken up with the provincial office by the DMT.<br />
In the longer term, the DMT should aim to develop facilities <strong>an</strong>d protocols for<br />
the m<strong>an</strong>agement of even acutely ill psychiatric inpatients within the district,<br />
thus avoiding the need for referral to Provincial level of what should be a<br />
district-level service. This facility would enh<strong>an</strong>ce the capacity of the specialist<br />
psychiatric staff to deliver a high quality of care within district boundaries.<br />
Psychiatry ought to move towards the models of care evident within other<br />
specialties, such as paediatrics, which rely upon local generalist medical staff<br />
rather th<strong>an</strong> consult<strong>an</strong>ts.<br />
Finally, it is worth noting that some specialist services, specifically mental<br />
disability <strong>an</strong>d psychogeriatric services, are delineated as provincially rendered<br />
services. Lower Or<strong>an</strong>ge should therefore lobby the provincial office for the<br />
creation of services in these areas.<br />
2. Pl<strong>an</strong>ning <strong>an</strong>d information<br />
Pl<strong>an</strong>s have already been laid at DMT level for taking over the operational<br />
m<strong>an</strong>agement of the psychiatric service. However, the DMT’s responsibilities in<br />
taking on mental health must develop beyond pure operational m<strong>an</strong>agement<br />
into a more strategic role: the monitoring of the service’s success rates <strong>an</strong>d<br />
<strong>an</strong>alysing the quality of service delivered must be carefully undertaken,<br />
especially in the period following tr<strong>an</strong>sfer into the community.<br />
It is crucial that decisions about what indicators might be appropriate <strong>an</strong>d<br />
valuable within the local context are reached collectively by local staff, including<br />
the DMT. For example, pertinent data might include the district suicide rate<br />
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(both of the community as a whole <strong>an</strong>d of known psychiatric patients).<br />
Alternatively, it might simply be a comparison of national figures for prevalence<br />
rates of various mental illnesses against local figures with regard to targeting of<br />
prevention services.<br />
The White Paper recommends that DMTs should be trained to improve their<br />
capacity to supervise, monitor <strong>an</strong>d evaluate services <strong>an</strong>d programmes within<br />
their district. Some external training in developing the capacity <strong>an</strong>d knowledge<br />
of the Lower Or<strong>an</strong>ge DMT within this field may well be helpful as it is a new<br />
area for most staff.<br />
3. Training of staff<br />
Training of DMT level staff may be deemed necessary as described above.<br />
However, the main training agenda must of necessity primarily concern PHC<br />
staff. The White Paper places great emphasis upon the need for comprehensive<br />
training of PHC staff before integration of mental health services c<strong>an</strong> occur.<br />
Specifically, it suggests that:<br />
“Staff at the lower levels, i.e. clinics <strong>an</strong>d community health centres,<br />
should be trained to do basic screening <strong>an</strong>d counselling <strong>an</strong>d to identify<br />
<strong>an</strong>d refer patients for further assessment <strong>an</strong>d m<strong>an</strong>agement.”<br />
Of course, m<strong>an</strong>y of the PHC Sisters, particularly those more recently trained,<br />
have completed a psychiatric element to their training <strong>an</strong>d m<strong>an</strong>y of these<br />
maintain a high level of knowledge <strong>an</strong>d skill within this area. Others however<br />
feel that their diagnostic skills <strong>an</strong>d knowledge base have been reduced due to<br />
lack of use. Yet <strong>an</strong>other group of PHC nurses have never received <strong>an</strong>y training<br />
in mental health. In order to ensure that all staff share a common knowledge<br />
base which is up to date with recent developments, a common training<br />
programme should be delivered to all PHC staff.<br />
One d<strong>an</strong>ger which seems to be evident within the district is to assume that a<br />
PHC clinic will cope with psychiatric patients if some, or at least one of its<br />
nursing staff is trained in psychiatry; of the PHC clinics within the district, only<br />
Keimoes <strong>an</strong>d one of the four Upington clinics have no staff trained in psychiatric<br />
care. The suggestion seems to be that only staff whose basic training included<br />
a psychiatric component should undertake care of the psychiatric patient. This<br />
approach is worrying for two reasons:<br />
• it fails to de-segregate psychiatric patients from all other patients <strong>an</strong>d<br />
facilitate the identification of mental health problems in all patients who pass<br />
through the clinic<br />
• it is not a workable solution in that there will be no staff to see a psychiatric<br />
patient whenever the appropriate member(s) of staff are on leave or off<br />
duty<br />
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It is therefore recommended that all staff undergo training <strong>an</strong>d that emphasis<br />
be put upon complete integration of mental health care within the clinic<br />
environment. On the basis of this study’s findings <strong>an</strong>d of the m<strong>an</strong>y suggestions<br />
made by healthcare staff who participated in this study, a training programme<br />
containing the following components is suggested:<br />
SUGGESTED TRAINING PROGRAMME FOR PHC NURSES<br />
1. The concept of mental health (<strong>an</strong>d its distinction from a narrow notion of<br />
psychiatric illness).<br />
2. Acknowledging <strong>an</strong>d overcoming fears about mentally ill patients<br />
3. How to recognise the earliest signs <strong>an</strong>d symptoms of mental ill health<br />
4. Basic listening skills – how to ask the right questions<br />
5. Psychiatric medications – what, when, how<br />
6. How to spot signs of relapse <strong>an</strong>d the need for a ch<strong>an</strong>ge of medications<br />
<strong>an</strong>d/or referral<br />
7. Referral protocols<br />
8. The role of the family in care for the patient <strong>an</strong>d in ensuring compli<strong>an</strong>ce<br />
9. Coping with violence <strong>an</strong>d aggression<br />
10. The need to follow up defaulting patients<br />
During the study, acute concern was expressed by PHC nurses that the training<br />
is provided before they take on responsibility for psychiatric patients. Some<br />
cited the tr<strong>an</strong>sfer of curative services into their remit as <strong>an</strong> example of being<br />
given the workload <strong>an</strong>d only afterwards being given the training. Clearly all<br />
efforts should be made to ensure that this situation does not occur again.<br />
4. Prevention <strong>an</strong>d promotion work<br />
In this area, the suggestions made in the White Paper concur totally with the<br />
suggestions made at local level. All role players in healthcare provision agree<br />
that there is <strong>an</strong> urgent need for the systematic provision of health education<br />
<strong>an</strong>d promotion activities aimed at preventing mental health problems.<br />
Schools work<br />
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The most immediate need was universally felt to be <strong>an</strong> education programme in<br />
schools. The issues which were most commonly identified as those which<br />
needed to be addressed through such a programme were:<br />
• Subst<strong>an</strong>ce abuse (both alcohol <strong>an</strong>d dagga)<br />
• Safer sex/AIDS/teenage pregn<strong>an</strong>cy/STDs<br />
• Physical <strong>an</strong>d sexual abuse<br />
• Stress<br />
• Teenage suicide<br />
The psychiatric nurses were particularly keen to train groups of teachers in the<br />
identification of mental health problems amongst their pupils as a me<strong>an</strong>s to<br />
reducing the number of teenage suicides <strong>an</strong>d attempted suicides.<br />
Community Education<br />
It was also widely felt that the community as a whole has very little<br />
underst<strong>an</strong>ding of mental health. Particip<strong>an</strong>ts in the focus group of PHC staff<br />
argued that their role in referring patients to the psychiatric service was<br />
hampered by the common perception that people with psychiatric illness were<br />
uniformly <strong>an</strong>d simply “mad”. M<strong>an</strong>y PHC nurses reported that families <strong>an</strong>d the<br />
community had little vocabulary available to them with which to deal with<br />
mental health problems around them; the repeated sole word in use was<br />
“mad”. It was felt that a programme or campaign of adult education was<br />
necessary to educate the local communities about the causes <strong>an</strong>d nature of<br />
mental ill-health. M<strong>an</strong>y PHC nurses argued strongly for education which gave<br />
people <strong>an</strong> underst<strong>an</strong>ding the biological bases of mental illness <strong>an</strong>d explained<br />
the most common forms of mental illness such as depression. It may be hoped<br />
that such a programme may also develop the communities’ willingness to be<br />
active particip<strong>an</strong>ts in caring for the mentally ill <strong>an</strong>d in preventing mental illhealth.<br />
5. Intersectoral liaison<br />
The White Paper suggests that liaison should occur at district level with NGOs,<br />
private practitioners <strong>an</strong>d traditional healers.<br />
Within Lower Or<strong>an</strong>ge, however, the most urgent priorities for development of<br />
relationships outside the Department of <strong>Health</strong> <strong>an</strong>d Welfare are with tr<strong>an</strong>sport<br />
services, the police <strong>an</strong>d the Department of Education. These relationships<br />
should be built up at district level to support collaborative working at<br />
community level, particularly with regard to education, where the authority of a<br />
“high level” agreement is needed in order to encourage schools to accept their<br />
role in health education. In addition it is worth noting that a closer working<br />
relationship between the two sections of the Department of <strong>Health</strong> <strong>an</strong>d Welfare<br />
would in itself be extremely valuable.<br />
Further intersectoral liaison needs are outlined in the next chapter.<br />
4.4 The role of the psychiatric nurse practitioner<br />
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If the DMT goes ahead with implementing <strong>an</strong>y degree of integration of curative<br />
mental health services to PHC level, a question mark is obviously created over<br />
the roles of the two members of staff currently providing that service.<br />
It is recommended that this question mark is used as <strong>an</strong> opportunity to develop<br />
the scope for the of the role of the psychiatric nurse practitioners. Drawing<br />
solely on the national framework outlined above, their future roles could include<br />
some or all of the following:<br />
• Training <strong>an</strong>d supervision of PHC nurses in identification <strong>an</strong>d referral<br />
• m<strong>an</strong>agement <strong>an</strong>d stabilisation of new or relapsed patients<br />
• education within the community, especially within schools<br />
• provision of <strong>an</strong> emergency or crisis intervention service<br />
• provision of alternative therapies such as counselling (after training<br />
as appropriate)<br />
• provide a limited “day hospital service” for observation <strong>an</strong>d therapy<br />
with patients during the day<br />
• m<strong>an</strong>age psychiatric inpatients admitted as short term patients (48/72<br />
hours) to Gordonia Hospital for stabilisation <strong>an</strong>d observation<br />
Which of these responsibilities are taken on by the nurses concerned is a<br />
matter for negotiation between the DMT <strong>an</strong>d the two nurses over the coming<br />
months.<br />
4.5 M<strong>an</strong>agement <strong>an</strong>d accountability arr<strong>an</strong>gements<br />
The accountability structures currently in place are fairly complex:<br />
• The salaries of the two psychiatric nurses have recently been tr<strong>an</strong>sferred<br />
such that they are now paid by the district<br />
• The district PHC Chief Professional Nurse provides direct m<strong>an</strong>agement<br />
support, in the form of authorising leave etc.<br />
• The personnel files for the two staff still remain in West End Hospital,<br />
Kimberley<br />
• Clinical accountability remains with West End Hospital<br />
• Operational m<strong>an</strong>agement of the service is the responsibility of the m<strong>an</strong>ager<br />
of the provincial mental health programme based in Kimberley.<br />
The psychiatric nurses feel very strongly that their clinical accountability must<br />
be to the West End psychiatrist, Mr Piotrowski. This is a long-st<strong>an</strong>ding<br />
arr<strong>an</strong>gement which reflects the fact that the two Upington posts were until<br />
recently employed by the Provincial Department of <strong>Health</strong>. An good working<br />
relationship is still enjoyed with West End which certainly helps the service run<br />
smoothly. Furthermore, the psychiatric nurses clearly feel that on clinical<br />
issues, the only appropriate person to whom they should be accountable is<br />
<strong>an</strong>other experienced psychiatric specialist.<br />
It is not clear whether the DMT forsee that the clinical m<strong>an</strong>agement of the<br />
service will also tr<strong>an</strong>sfer to them from April 1999. If this is indeed deemed to<br />
be necessary, such that the psychiatric services are fully devolved to the district<br />
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level, discussions between the psychiatric nurses, West End <strong>an</strong>d the DMT will<br />
be necessary.<br />
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PROJECT PLAN: INTEGRATION OF MENTAL HEALTH SERVICES (OPTION B MODEL)<br />
1. Project m<strong>an</strong>agement <strong>an</strong>d strategy<br />
Integration of the service will take m<strong>an</strong>y moths, if not years, <strong>an</strong>d will involve m<strong>an</strong>y people. Such a complex project requires a team to pl<strong>an</strong><br />
<strong>an</strong>d monitor its progress <strong>an</strong>d who will take clear charge of the ch<strong>an</strong>ge process. The team should include key roleplayers such as the<br />
provincial m<strong>an</strong>ager of the mental health programme, the DMT’s CPN in charge of PHC, the psychiatric nurses <strong>an</strong>d the district pharmacist.<br />
The first task of the team is to agree what the aims of integration are <strong>an</strong>d to agree a vision of what the service should look like in three<br />
years’ time. Secondly, responsibility for each specific stage of this project pl<strong>an</strong> must be allocated amongst the group.<br />
1. Establish a project team<br />
2. Establish visions <strong>an</strong>d aims<br />
3. Agree project pl<strong>an</strong> <strong>an</strong>d a broad implementation timetable <strong>an</strong>d allocate responsibilities for each step<br />
4. Address question of mental health representation on the DMT<br />
5. Visit Springbok <strong>an</strong>d De Aar as a fact-finding trip<br />
6. Choose one pilot site (of three outreach services 7 ) <strong>an</strong>d agree with the PHC staff there a date for integration<br />
7. Org<strong>an</strong>ise meeting with patients <strong>an</strong>d families to explain the ch<strong>an</strong>ges <strong>an</strong>d meet the PHC staff<br />
8. Monitor pilot site for three months <strong>an</strong>d learn lessons<br />
9. Roll out integration to two other clinics<br />
10. Gradually tr<strong>an</strong>sfer Upington patients to local clinics<br />
7 i.e. one of Kenhardt, Keimoes or Kakamas, as the patients at these clinics will only see a new nurse but do not need to tr<strong>an</strong>sfer to a new clinic as in Upington<br />
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2. Information requirements<br />
There are m<strong>an</strong>y aspects of the integration which c<strong>an</strong>not be pl<strong>an</strong>ned or implemented successfully without a complex <strong>an</strong>alysis of information<br />
beforeh<strong>an</strong>d. For example, to identify which psychotropic drugs will need to be stocked by each PHC clinic, the team will require information<br />
about which patients will be seen in which clinic <strong>an</strong>d what medications they each receive. If integration occurs without this information<br />
having been gathered, PHC clinics will not have the medications available at the right time for patients, which may have serious<br />
consequences. Similarly, if clear information is not available regarding which patients will tr<strong>an</strong>sfer to which clinics, their medical records<br />
c<strong>an</strong>not be moved to the appropriate location. Completing all the following stages of information gathering is therefore a pre-requisite of<br />
beginning the actual tr<strong>an</strong>sfer of patients.<br />
1. Devise criteria to distinguish “simple to tr<strong>an</strong>sfer” patients from “complex” patients<br />
2. Establish how well known the psychiatric patients are to the PHC nurses<br />
3. Allocate patients now seen centrally in Upington to local clinics based on their addresses<br />
4. Agree with psychiatric nurses <strong>an</strong>d PHC clinics exact numbers <strong>an</strong>d identities of patients to be tr<strong>an</strong>sferred to each clinic (= 1 + 2 + 3)<br />
5. Based on 4, pl<strong>an</strong> for the tr<strong>an</strong>sfer of patients’ medical records to the clinics (must occur prior to complete h<strong>an</strong>dover of patients)<br />
6. Gain data from the Province necessary to pl<strong>an</strong> for taking over the drug postal service (qu<strong>an</strong>tities, frequency, cost etc.)<br />
7. Gain data from the Upington psychiatric nurses regarding each patient’s medications <strong>an</strong>d (using information 4. Above), calculate<br />
therefore what the drug needs of each PHC clinic will be<br />
8. Calculate therefore what the dem<strong>an</strong>ds on the Gordonia pharmacy will be for monthly distribution of drugs ( = 5 + 6)<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
3. Training<br />
PHC nurses will require both formal “academic” training in psychiatric work <strong>an</strong>d also informal training through supervision as they begin to<br />
see psychiatric patients. Both these forms of training MUST occur before complete h<strong>an</strong>dover of patients c<strong>an</strong> occur, although supervision of<br />
PHC nurses should continue for some time after integration occurs. It is import<strong>an</strong>t that both provincial <strong>an</strong>d local sources of expertise are<br />
used to deliver the training <strong>an</strong>d the content of the course should be agreed by the entire project team. A suggested agenda for the<br />
training course is included in 4.4.3 above). A further decision needs to be made as to whether all PHC nurses will be trained or solely those<br />
with no prior psychiatric training. However, it is not only nursing staff who require training: the White Paper dem<strong>an</strong>ds that DMT receive<br />
some training in the m<strong>an</strong>agement of a psychiatric service so that they are able to monitor <strong>an</strong>d evaluate its perform<strong>an</strong>ce, using appropriate<br />
indicators <strong>an</strong>d underst<strong>an</strong>ding the main clinical issues around psychiatric services.<br />
1. Identify the proportion of PHC nurses with previous psychiatric training <strong>an</strong>d their distribution across the clinics<br />
2. Agree content of local programme for training of PHC nurses including new referral protocols between PHC <strong>an</strong>d psychiatric nurses for<br />
new, complex or non-compli<strong>an</strong>t patients, <strong>an</strong>d new job descriptions for psychiatric nurses (see below)<br />
3. Establish what support <strong>an</strong>d training Province will offer <strong>an</strong>d agree who will deliver the training<br />
4. Agree timetable for training of nurses: should outlying clinics be prioritised for training first (as they will receive patients first) or should<br />
there be a mixture of staff from each clinic?<br />
5. Deliver formal training modules to PHC nurses in groups<br />
6. Alongside formal training, familiarise PHC nurses with psychiatric work <strong>an</strong>d the patients by sitting in <strong>an</strong>d watching psychiatric clinics led<br />
by the psychiatric nurses<br />
7. Increase PHC nurses participation in the clinic sessions such that patients are jointly m<strong>an</strong>aged<br />
8. Gradually move to a point where the PHC nurses m<strong>an</strong>ages the patients <strong>an</strong>d the psychiatric nurse takes on a supervision role only<br />
9. Establish the training needs of the DMT to take on m<strong>an</strong>agement of the service (ability to monitor indicators, intersectoral issues)<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
4. Budget Tr<strong>an</strong>sfer <strong>an</strong>d Fin<strong>an</strong>cial M<strong>an</strong>agement<br />
Tr<strong>an</strong>sfer of the costs associated with provision of the service from the provincial level to the district should not be one of the more complex<br />
matters. However, it is import<strong>an</strong>t that integration into PHC does not me<strong>an</strong> that money previously spent on psychiatric services is now<br />
filtered into PHC; integration is not designed to produce a cheaper service but to improve the quality of the service. In order to prevent<br />
this occurring, the first step is to establish a specific cost centre for mental health <strong>an</strong>d to tr<strong>an</strong>sfer each cost item into that cost centre. This<br />
will allow for comparison over time of expenditure on mental health. Experience in countries such as the UK ahs shown that tr<strong>an</strong>sferring<br />
care into the community is not a cheaper option th<strong>an</strong> maintaining a specialised service <strong>an</strong>d should not be viewed as <strong>an</strong> opportunity to save<br />
money. The DMT should commit itself to maintaining over 5 years the proportion of its expenditure which goes towards mental health<br />
services.<br />
A potential difficulty with stage 4 of the tr<strong>an</strong>sfer of budgets may occur if the provincial fin<strong>an</strong>cial m<strong>an</strong>agement system is unable to identify<br />
expenditure on pharmaceuticals sent to the Lower Or<strong>an</strong>ge district as a part of the main provincial pharmaceuticals budget. Without this<br />
information, it will be difficult to ensure that <strong>an</strong> appropriate amount is tr<strong>an</strong>sferred over to the district to fin<strong>an</strong>ce drug costs. The only way<br />
to establish <strong>an</strong> appropriate figure in this situation will be to calculate the cost per year based on the drug stock ordering records kept in the<br />
Upington clinic. This will not however help with identifying the expenditure within the postal system to Lower Or<strong>an</strong>ge.<br />
1. Establish a new ringfenced cost centre for mental health within DMT budget (separate from PHC)<br />
2. Tr<strong>an</strong>sfer salaries of two psychiatric nurses from Province<br />
3. Tr<strong>an</strong>sfer miscell<strong>an</strong>eous non-pay expenditure from Province (travel expenses to clinics, stationary, printed appointment cards)<br />
4. Tr<strong>an</strong>sfer pharmaceuticals expenditure from Province (cost of supply to the Upington clinic nurses plus the postal service to Lower<br />
Or<strong>an</strong>ge clinics)<br />
5. Investigate what “share” of inpatient expenditure at West End Hospital is dedicated to Lower Or<strong>an</strong>ge <strong>an</strong>d whether there is potential for<br />
tr<strong>an</strong>sfer of these monies into the district to fund development of <strong>an</strong> inpatient facility within the district<br />
6. Once all above elements have been tr<strong>an</strong>sferred into the district budget, calculate the expenditure on mental health as a proportion of<br />
total district expenditure. This figure should not decrease over time.<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
5. Development of psychiatric nurse post<br />
The success of <strong>an</strong> <strong>integrated</strong> system hinges upon the quality of the referral process <strong>an</strong>d the supervision <strong>an</strong>d support that generalist nursing<br />
staff c<strong>an</strong> call upon. PHC nurses need the confidence that they will have easy access to specialist advice <strong>an</strong>d c<strong>an</strong> refer a patient whenever<br />
they are concerned. Integration in Lower Or<strong>an</strong>ge offers the district the opportunity to develop the quality <strong>an</strong>d scope of its services<br />
considerably without spending <strong>an</strong>y extra money, simply by tr<strong>an</strong>sferring patient loads away from the specialist staff <strong>an</strong>d thereby allowing<br />
them to spend more time working closely with difficult patients <strong>an</strong>d developing services for specific client groups such as children <strong>an</strong>d<br />
adolescents or victims of violence. For this system to work well, however, good pl<strong>an</strong>ning is necessary to establish very clear referral<br />
protocols <strong>an</strong>d ensure that there is clarity amongst all health care staff as to each others’ roles within the system. The post of the<br />
psychiatric nurse will ch<strong>an</strong>ge: during the integration period, they will be required to spend much of their time training <strong>an</strong>d supervising. As<br />
the new model falls into place, the psychiatric nurses will be able to take on m<strong>an</strong>y of the previously lacking aspects of the service, such as<br />
provision of counselling <strong>an</strong>d a child <strong>an</strong>d adolescent service.<br />
1. Clarify vision of services as above<br />
2. Identify role of psychiatric nurse within this model in clear written job descriptions:<br />
a) during tr<strong>an</strong>sitional period as integration occurs: supervision <strong>an</strong>d training<br />
b) on completion of tr<strong>an</strong>sition: ongoing supervision of PHC nurses, m<strong>an</strong>agement <strong>an</strong>d treatment of new, “complex” <strong>an</strong>d non-compli<strong>an</strong>t<br />
patients, provision of alternative therapies <strong>an</strong>d preventive/educational work, inter-sectoral liaison with Welfare <strong>an</strong>d Education<br />
3. Agree clear referral protocols between PHC <strong>an</strong>d psychiatric nurses for new <strong>an</strong>d “complex”, <strong>an</strong>d non-compli<strong>an</strong>t patients (which must then<br />
be included in PHC nurses’ training as above)<br />
4. Provide training to the post holders as necessary, e.g “training the trainers” course, counselling skills, child <strong>an</strong>d adolescent mental<br />
health, health promotion, domestic violence<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
6. Drugs M<strong>an</strong>agement<br />
Ensuring that a supply of drugs is available at each clinic is essential to successful integration. The process of developing a district<br />
distribution system is complicated by uncertainty over the timing of the completion of the district’s new pharmacy within Gordonia Hospital<br />
<strong>an</strong>d the potential development of a second provincial drugs depot within Upington. The other major issue around drugs m<strong>an</strong>agement<br />
concerns the dispensing of Schedule 5 drugs from PHC clinics for the first time, which will require specific training for clinic staff. However,<br />
there should be no need for drugs shortages as it is entirely possible to predict the dem<strong>an</strong>ds of each clinic using existing data. It is<br />
therefore vital that this <strong>an</strong>alysis is carried out <strong>an</strong>d that a very detailed distribution system, based upon this information, is established.<br />
1. Establish a drugs m<strong>an</strong>agement group to oversee the tr<strong>an</strong>sfer, to include the regional pharmacist <strong>an</strong>d the provincial lead on drug issues<br />
2. Identify how the timing of the integration will coincide with the completion of the Gordonia Hospital new pharmacy block; where will the<br />
district’s supply of psychiatric drugs be kept in the me<strong>an</strong>time?<br />
3. Establish the exact monthly dem<strong>an</strong>d for drugs at each clinic on the basis of information as above<br />
4. Draw up a pl<strong>an</strong> for the monthly distribution of psychiatric drugs to each clinic<br />
5. Work with PHC clinics on the incorporation of psychiatric drugs into clinic drug stores; ensure that rational drug use m<strong>an</strong>agement is<br />
applied i.e. establish minimum <strong>an</strong>d maximum ordering levels, use of stock cards<br />
6. Train PHC nurses in specific storage, prescribing <strong>an</strong>d dispensing issues for Schedule 5 drugs<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
7. Tr<strong>an</strong>sfer of Patients<br />
This is the final stage of the process <strong>an</strong>d should not be undertaken until all other steps above have been completed. Most import<strong>an</strong>tly,<br />
systems for drug distribution must be firmly in place <strong>an</strong>d training of all PHC staff must have been completed. It should be remembered<br />
that m<strong>an</strong>y psychiatric patients have been attending the same clinic <strong>an</strong>d seeing the same staff within a set routine for m<strong>an</strong>y years <strong>an</strong>d that<br />
such a ch<strong>an</strong>ge may for some be extremely difficult for them to m<strong>an</strong>age. It is import<strong>an</strong>t to recognise that patients have developed a<br />
therapeutic relationship with the psychiatric nurses over m<strong>an</strong>y years which will not be easily replicated with a new nurse. Although the<br />
ch<strong>an</strong>ge process is hard for staff, it should be remembered that those who may really struggle will be the patients.<br />
1. Identify which patients tr<strong>an</strong>sfer will tr<strong>an</strong>sfer to each clinic <strong>an</strong>d “complex patients” who will remain under the care of the psychiatric<br />
nurses<br />
2. Inform the patients individually of the ch<strong>an</strong>ge to their treatment routine; for some, the ch<strong>an</strong>ge will be solely of personnel, for others<br />
they will have to attend a different clinic altogether<br />
3. Meeting with patients <strong>an</strong>d their families in each of the four towns to explain the ch<strong>an</strong>ge process.<br />
4. Tr<strong>an</strong>sfer care gradually, with psychiatric nurses in attend<strong>an</strong>ce as well as PHC nurses for the first months’ visits<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Chapter 5<br />
Strategy for future development<br />
The final chapter consists of <strong>an</strong> action pl<strong>an</strong> to address the future of the<br />
psychiatric service as a whole as it develops into a modern mental health<br />
service. The following recommendations are based on the findings of the<br />
situation <strong>an</strong>alysis <strong>an</strong>d include actions both for the short-term <strong>an</strong>d for the very<br />
long-term. M<strong>an</strong>y of them arise from the suggestions <strong>an</strong>d ideas of the health<br />
workers who participated in the study. However it is recognised that certain<br />
long-term recommendations to some extent constitute a wish list impossible to<br />
deliver under present resource constraints (in hum<strong>an</strong> resources as well as<br />
fin<strong>an</strong>ces). They are included in part to give <strong>an</strong> idea of service levels in other<br />
parts of the country <strong>an</strong>d should ideally exist in the Northern Cape as well.<br />
1. <strong>Health</strong> Education <strong>an</strong>d Community Involvement<br />
Problem Statement:<br />
1. High incidence of mental health problems which relate to dagga use <strong>an</strong>d<br />
teenage pregn<strong>an</strong>cy <strong>an</strong>d could therefore be prevented<br />
2. Lack of community underst<strong>an</strong>ding of mental health causes stigmatisation of<br />
patients <strong>an</strong>d a perception of the mentally ill as a threat<br />
3. Families unable to identify symptoms in early stages of illness, so<br />
presentation to the service is delayed until illness is acute<br />
4. No community involvement in pl<strong>an</strong>ning of the service<br />
5. No community involvement in peer education programmes or support groups<br />
Short term recommendations:<br />
1. Urgently liaison with the Education <strong>an</strong>d Welfare Departments to develop<br />
jointly a local schools health education strategy to include subst<strong>an</strong>ce abuse<br />
<strong>an</strong>d safer sex education<br />
2. Extend the health promotion component of the psychiatric nurse post<br />
Medium term recommendations:<br />
1. Set up a Community <strong>Mental</strong> <strong>Health</strong> Forum to include key role players such as<br />
teachers, local councillors <strong>an</strong>d religious leaders<br />
2. Establish a community education programme around child physical <strong>an</strong>d<br />
sexual abuse <strong>an</strong>d a support group for women who have experienced<br />
domestic violence<br />
Long-term recommendations:<br />
1. Meet with church leaders to establish better relations <strong>an</strong>d communication<br />
2. Meet with traditional healers to discuss referrals <strong>an</strong>d communication<br />
3. Establish a joint team of community workers between <strong>Health</strong> <strong>an</strong>d Welfare<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
2. Information<br />
Problem Statement:<br />
1. Time is spent on form filling without benefit or feedback<br />
2. Data exists but is not <strong>an</strong>alysed or used for pl<strong>an</strong>ning<br />
3. There is no way of measuring the success or improvement of the service <strong>an</strong>d<br />
consequently no targets c<strong>an</strong> be set<br />
4. No data collated about diagnoses creating difficulties for decisions about mental<br />
health priorities <strong>an</strong>d targeting of preventative work<br />
Short term recommendations:<br />
1. Identify <strong>an</strong>y unnecessary collection of data <strong>an</strong>d cease collection<br />
2. Allocate responsibility for <strong>an</strong>alysis <strong>an</strong>d feedback to one individual within the DMT<br />
3. Establish baseline information against which future results c<strong>an</strong> be compared e.g.<br />
• Proportion of population registered as psychiatric patients (per 10,000)<br />
• Proportion of patients whose illness is subst<strong>an</strong>ce-related<br />
Medium term recommendations<br />
1. Draw up a further list of data which would be useful to the district in pl<strong>an</strong>ning<br />
the future direction of mental health services (suggested indicators for<br />
evaluating mental health services are given in the 1995 White Paper as goals for<br />
health improvement by 2000) e.g.<br />
• numbers of children with mental disability not attending school<br />
• numbers of suicides (<strong>an</strong>d therefore rate per 100,000 population)<br />
• Areas in which subst<strong>an</strong>ce abuse is highest<br />
• Schools not currently running subst<strong>an</strong>ce abuse education<br />
• numbers of patients referred to forensic service per year<br />
2. Set local targets for improvements within stated timeframe e.g.<br />
• reduction in numbers of attempted suicides<br />
• reduction in number of patients referred to Kimberley<br />
Long-term recommendations<br />
1. Liaise with Welfare Department regarding victims of rape <strong>an</strong>d domestic violence<br />
known to social workers<br />
2. Commission research into prevalence rates of mental illness within the district<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
3. Scope of <strong>Service</strong>s<br />
Problem Statement:<br />
1. No state psychologist or counselling facilities other th<strong>an</strong> social workers<br />
2. Inpatient facilities only exist in Kimberley, which discourages short-term<br />
admissions due to dist<strong>an</strong>ce <strong>an</strong>d cost of travel<br />
3. No support service for patients or families out of hours needing urgent<br />
intervention to prevent violence or self-harm<br />
4. Casualty departments ill-prepared to m<strong>an</strong>age or admit acutely ill psychiatric<br />
patients, therefore patients detained in police cells<br />
5. No capacity amongst staff to provide therapies other th<strong>an</strong> pharmacalogical<br />
Short term recommendations:<br />
1. Work with Gordonia Hospital Casualty in improving protocols for admission<br />
<strong>an</strong>d m<strong>an</strong>agement of acute patients overnight, using hospital qualified staff<br />
<strong>an</strong>d psychiatric nurses as “consult<strong>an</strong>ts” when necessary<br />
2. Commence training of psychiatric staff in counselling skills<br />
3. Commence joint work with Welfare on provision of services for victims of<br />
rape/assault/sexual abuse/domestic violence to avoid duplication of efforts<br />
Medium term recommendations<br />
1. Develop <strong>an</strong> on-call 24 hour rota (budgetary implications)<br />
2. Liaise with police to ensure optimum conditions <strong>an</strong>d treatment of patients<br />
<strong>an</strong>d that police staff have some underst<strong>an</strong>ding of mental illness<br />
Long-term recommendations<br />
1. Work with Gordonia hospital to develop <strong>an</strong> inpatient service based on<br />
dedicated psychiatric beds under joint care of psychiatrically-qualified<br />
Gordonia staff <strong>an</strong>d psychiatric nurse practitioners<br />
2. Introduce a “lay/peer counsellors” scheme as in operation successfully in<br />
the Western Cape (Mossel Bay/L<strong>an</strong>geberg district)<br />
3. Work towards developing specialist child <strong>an</strong>d adolescent services to be run<br />
by the psychiatric nurses<br />
4. Liaise with old age homes regarding psychogeriatric patients, training staff<br />
to ensure that they have a basic underst<strong>an</strong>ding of mental illness, especially<br />
senile dementia<br />
5. Maintain pressure upon the Provincial department regarding the urgency of<br />
appointing a community-based psychologist<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
4. Role Clarification<br />
Problem Statement:<br />
1. Role of psychiatrist problematic: skill mix skewed such that most senior <strong>an</strong>d<br />
skilled member of the team has little opportunity to work closely with<br />
patients; his major role is approving <strong>an</strong>d signing prescriptions<br />
2. Little clarity regarding role of Casualty departments in out of hours service<br />
3. Epileptic patients frequently referred to psychiatric service although most<br />
should be m<strong>an</strong>ageable within PHC clinics<br />
4. Local family practitioners prescribe psychiatric medications prior to referral<br />
without consultation with psychiatric service, resulting in inappropriate<br />
treatment <strong>an</strong>d delay in onset of more appropriate treatment<br />
5. Some potential for future duplication between <strong>Health</strong> <strong>an</strong>d Welfare of<br />
service provision for victims of rape/abuse/assault as each currently pl<strong>an</strong>s<br />
to develop these services as a priority<br />
Short term recommendations:<br />
1. Bring together local family practitioners, psychiatric nurses <strong>an</strong>d psychiatrist<br />
to establish agreement regarding treatment protocols prior to referral<br />
2. Investigate whether the legal framework does necessitate a psychiatrist’s<br />
review of the prescriptions each year <strong>an</strong>d if possible, alter the system such<br />
that a doctor from Gordonia hospital fulfils this role 8 ; similarly, investigate<br />
the restrictions upon nurse prescribing of psychotropics <strong>an</strong>d the<br />
implications for integration of psychiatric services into PHC<br />
Medium term recommendations<br />
1. Ensure that “pre-integration training” for PHC staff includes training in<br />
m<strong>an</strong>agement of epileptic patients within PHC<br />
2. Bring the 4 community doctors who will be rotating through the PHC clinics<br />
as of J<strong>an</strong>uary into the psychiatric system <strong>an</strong>d potentially tr<strong>an</strong>sfer <strong>an</strong>nual<br />
review of prescriptions to them<br />
3. Liaise with Welfare to produce a synergy in the development of services<br />
rather th<strong>an</strong> duplication<br />
Long-term recommendations<br />
1. Draw up clear protocols displaying visually the role of each sector/individual<br />
within the process<br />
8 It is likely that the need for a psychiatrist to review the prescriptions once a year is a condition of the<br />
permit specifically issued to the Northern Cape’s psychiatric nurses under section 38A of the Nursing Act<br />
which allows them to initiate schedule 5 drugs for up to 5 months. This permit must have been issued<br />
under the authority of Mr Piotrowski <strong>an</strong>d could equally be altered by him.<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
5. Drugs <strong>an</strong>d prescribing<br />
Problem Statement:<br />
1. Drugs frequently do not arrive in the “postal system” to outlying clinics<br />
2. PHC clinics’ drugs store does not include psychiatric medications<br />
3. PHC professional nurses legally unable to dispense schedule 5 drugs<br />
4. Inefficient use of psychiatrist’s time in signing 200+ prescriptions<br />
5. Confusion as to potential location of a second provincial drugs depot in<br />
Upington<br />
6. The province proposes to decentralise the provincial drugs system to each<br />
district <strong>an</strong>d make distribution within districts the responsibility of the district<br />
pharmacist<br />
7. Budget for psychiatric drugs currently lies with the province<br />
Short term recommendations:<br />
1. Investigate the legal <strong>an</strong>d Nursing Council restrictions to gain clarity<br />
regarding the role of the psychiatrist <strong>an</strong>d the PHC nurses<br />
2. Prepare for the decentralisation to the district:<br />
a) establish from the province all the relev<strong>an</strong>t facts regarding the postal<br />
services, e.g. qu<strong>an</strong>tities, frequency<br />
b) Draw up a pl<strong>an</strong> for the distribution of the drugs within the province<br />
3. Ensure that all staff are aware that the postal service will cease<br />
4. Begin negotiations with the province for the tr<strong>an</strong>sfer of the drugs budget<br />
Medium term recommendations<br />
1. Ensure that PHC staff have adequate training in use <strong>an</strong>d storage of<br />
psychotropic drugs<br />
2. Work with the pharmacist at Gordonia Hospital to prepare for the creation<br />
of the psychiatric drugs store within the hospital pharmacy<br />
Long-term recommendations<br />
1. Tr<strong>an</strong>sfer <strong>an</strong>nual review of prescriptions to community or hospital doctors<br />
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<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
6. Tr<strong>an</strong>sport<br />
Problem Statement:<br />
1. M<strong>an</strong>y patients travel considerable dist<strong>an</strong>ces to receive their medications<br />
2. Inappropriate facilities for tr<strong>an</strong>sfer of patients to West End Hospital<br />
3. Police service does not accept responsibility for tr<strong>an</strong>sferring certified patients to<br />
Kimberley even if already charged with a criminal offence<br />
Short term recommendations:<br />
1. Collect data for a six month period to provide baseline information on which to<br />
base negotiations (numbers of patients, time of day/night etc.)<br />
2. Liaise with Gordonia Hospital so that the psychiatric service c<strong>an</strong> take adv<strong>an</strong>tage<br />
of emergency unscheduled trips made to Kimberley<br />
Medium term recommendations<br />
1. Bring together police, tr<strong>an</strong>sport, <strong>an</strong>d psychiatric nurses in a meeting convened<br />
by the Regional M<strong>an</strong>ager to agree a protocol for psychiatric patient tr<strong>an</strong>sport<br />
Long-term recommendations<br />
1. As the district develops its capacity to m<strong>an</strong>age acutely ill patients, the resulting<br />
reduction in referrals should make this less of a long-term problem.<br />
7. Staff <strong>an</strong>d Patient Safety<br />
Problem Statement:<br />
1. Inadequate facilities for the disposal of sharps at the Upington clinic<br />
threatens the safety of both patients <strong>an</strong>d staff<br />
2. No policy for action following exposure to blood is known to clinic staff<br />
Short term recommendations:<br />
1. Provide the clinic with adequate sharps disposal facilities<br />
2. Train the nursing staff not to build up such a stockpile of used sharps<br />
3. Provide a copy of the district/provincial/Gordonia policy for action post<br />
exposure to blood to the clinic <strong>an</strong>d agree a specific written policy for them<br />
46
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Bibliography <strong>an</strong>d References<br />
Bamford L (1997) Action for <strong>Health</strong> in Kakamas 1997/8, Initiative for Sub-<br />
District Support, Technical Report 2a, Durb<strong>an</strong><br />
Department of <strong>Health</strong> (1997) White Paper for the Tr<strong>an</strong>sformation of the <strong>Health</strong><br />
System in South Africa, Government Gazette No.17910, Pretoria<br />
Flisher, A. et al (1988), Norms <strong>an</strong>d St<strong>an</strong>dards for Psychiatric Care in South<br />
Africa, Department of Psychiatry, University of Cape Town<br />
<strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong> (1997) South Afric<strong>an</strong> <strong>Health</strong> Review 1997, Chapter 17:<br />
<strong>Mental</strong> <strong>Health</strong>, Durb<strong>an</strong><br />
Helser J.E. <strong>an</strong>d Pyzbeck T.R. (1988), The co-occurrence of alcoholism with<br />
other psychiatric disorders in the general population <strong>an</strong>d its impact upon<br />
treatment, Journal of Studies on Alcohol, 49, 219-224<br />
Jones L (1998) <strong>Mental</strong> <strong>Health</strong> Care in Mount Frere, Initiative for Sub-District<br />
Support, <strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong>, Durb<strong>an</strong><br />
Muller L. et al (1988) <strong>Mental</strong> <strong>Health</strong> Integration at the District Level in the<br />
Western Cape, Department of Psychiatry, University of the Western Cape, work<br />
in progress<br />
Peterson I.(1988) Training for Tr<strong>an</strong>sformation: Reorientating Primary <strong>Health</strong><br />
Care Nurses for the Provision of <strong>Mental</strong> <strong>Health</strong> Care in South Africa, Department<br />
of Psychology, University of Durb<strong>an</strong>-Westville, unpublished<br />
Peterson I.(1988) Org<strong>an</strong>isational Barriers to Comprehensive Integrated Primary<br />
<strong>Mental</strong> <strong>Health</strong> Care, Department of Psychology, University of Durb<strong>an</strong>-Westville,<br />
work in progress<br />
47
Table 1<br />
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Appendix 1<br />
Patients under care of psychiatric service by locality<br />
Patients seen by Psychiatric nurses in Keimoes<br />
July 1997 – June 1998<br />
Jul Aug Sep Oct Nov Dec J<strong>an</strong> Feb Mar Apr May Jun<br />
First<br />
Visit<br />
Male/<br />
Female<br />
Follow<br />
-up<br />
visit<br />
0 2 0 0 1 1 0 1 1 0 0 0<br />
0 0 0 2 0 0 0 0 0 1 0 1 0 0 1 0 1 0 0 0 0 0 0 0<br />
55 59 55 62 61 54 53 54 56 56 66 60<br />
Home<br />
Visits<br />
0 0 0 0 0 0 0 0 0 0 0 0<br />
Did Not<br />
Attend<br />
6 8 16 10 9 15 0 9 7 10 14 3 8<br />
• No home visits<br />
• Fairly even number of patients each month <strong>an</strong>d a lower default rate<br />
proportional to the total number of patients th<strong>an</strong> Upington<br />
9 There are no defaulters in J<strong>an</strong>uary as a new register is started<br />
48
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Table 2<br />
Patients seen by Psychiatric nurses in Upington<br />
July 1997 – June 1998<br />
July Aug Sep Oct Nov Dec J<strong>an</strong> Feb Mar Apr May Jun<br />
First<br />
Visit<br />
Male<br />
/Female<br />
5 7 8 3 12 6 8 8 13 6 14 9<br />
2 3 4 3 5 3 2 1 4 8 5 1 7 1 2 5 5 8 4 2 5 9 4 5<br />
Follow<br />
-up<br />
visit<br />
448 479 481 652<br />
*<br />
438 452 432 430 515 598<br />
*<br />
439 532<br />
Home<br />
Visits<br />
60 63 72 84 84 42 63 73 97 73 74 108<br />
Did Not<br />
Attend<br />
91 88 89 83 114 147 0 10 47 53 67 96 80<br />
* The numbers of patients attending the clinic are higher in October <strong>an</strong>d April as these are the<br />
months in which the provincial psychiatrist visits Upington. M<strong>an</strong>y patients c<strong>an</strong>not afford to<br />
attend the clinic frequently <strong>an</strong>d so will see the nurses as well as the psychiatrist during this<br />
visit.<br />
Comments<br />
• Very high number of defaulters, especially around November/December when seasonal<br />
work availability in vineyards outside the region is highest<br />
• Home visits include patients in old age homes <strong>an</strong>d in prison; yet breaking down the home<br />
visits by age demonstrates that only a small percentage are to patients over 65; rather, the<br />
41-64 age group make up a higher proportion of home visits th<strong>an</strong> of clinic visits. This is in<br />
part due to the fact that one of the so-called old age homes, ND Swartz, also doubles as a<br />
centre for people of all ages in need of care, e.g. adults with severe learning disabilities, the<br />
physically disabled<br />
• Breakdown by age (not given) reveals the largest category of patients to be between 19<br />
<strong>an</strong>d 40 years of age; no children under 5 were seen, which suggests that <strong>an</strong> appropriate<br />
distinction is being made between children with learning difficulties <strong>an</strong>d adults with mental<br />
illness. There may however be lack of provision for adolescents: there were only 18 visits<br />
by patients between 6 <strong>an</strong>d 18 in the entire year, m<strong>an</strong>y of which may well be made by the<br />
same one or two patients. Compared to the national figures for adolescent mental health<br />
problems, this may suggest gaps in targeting <strong>an</strong>d access.<br />
10 There are no defaulters in J<strong>an</strong>uary as a new register is started<br />
49
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Table 3<br />
Patients seen by Psychiatric nurses in Kakamas<br />
July 1997 – June 1998<br />
Jul Aug Sep Oct Nov Dec J<strong>an</strong> Feb Mar Apr May Jun<br />
First<br />
Visit<br />
Male/<br />
Female<br />
Follow<br />
-up<br />
visit<br />
0 0 1 0 0 1 0 0 0 0 0 1<br />
0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1<br />
48 48 45 43 40 42 43 47 46 92 11 49 51<br />
Home<br />
Visits<br />
0 1 1 0 0 0 0 0 0 0 0 0<br />
Did Not<br />
Attend<br />
4 3 8 9 14 12 0 12 1 3 2 3 2<br />
• All the new patients are female – is this signific<strong>an</strong>t?<br />
• Default rate signific<strong>an</strong>t only around November/December time, at which<br />
time numbers of patients seen is at its lowest; clear pattern over the year,<br />
rising to a peak in winter<br />
11 There were two visits to Kakamas in April, therefore these figures are the combined total of the two<br />
visits<br />
12 There are no defaulters in J<strong>an</strong>uary as a new register is started<br />
50
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Table 4<br />
Patients seen by Psychiatric nurses in Kenhardt<br />
July 1997 – June 1998<br />
July Aug Sep Oct Nov Dec J<strong>an</strong> Feb Mar Apr May Jun<br />
First<br />
Visit<br />
1 3 0 0 1 0 0 1 0 0 0 0<br />
Male/ 1 0 2 1 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0<br />
Female<br />
Followup<br />
visit<br />
38 35 37 35 40 36 36 38 44 39 37 35<br />
Home<br />
Visits<br />
1 1 1 1 1 1 1 1 1 2 1 1<br />
Did<br />
Not<br />
Attend<br />
2 9 11 11 6 10 0 5 0 5 6 8<br />
• The one home visit each month is to one individual who is unable to attend<br />
the clinic due to his delusional state<br />
• A higher default rate proportionately to the other outreach clinics at<br />
between 15% <strong>an</strong>d 23%<br />
51
<strong>Towards</strong> <strong>an</strong> Integrated <strong>Mental</strong> <strong>Health</strong> <strong>Service</strong><br />
Appendix 2<br />
List of clinics represented in the focus group of PHC nurses<br />
Clinic<br />
Paballelo Clinic<br />
Louisvaleweg Clinic<br />
Pofadder Municipal Clinic<br />
Grobelershoop Clinic<br />
SA Defence Forces, Upington Base clinic<br />
Upington Prison clinic<br />
The focus group was held on Thursday 8 th October at Upington Fire Station.<br />
Nursing staff from Kakamas Hospital <strong>an</strong>d Gordonia Hospital also participated in<br />
the discussion.<br />
52