Mental health services in KwaZulu-Natal

This article is a summary of a document prepared by a task team appointed by the Superintendent-General, Head: Department of Health, KwaZulu-Natal. The terms of reference of the task team were to scrutinise all available documents on mental health in the province and to come up with a new doc- ument entitled ‘Strategic and Implementation Plan for Delivery of Mental Health Services in KwaZulu-Natal’, with operational plans and time frames, and to make specific recommendations with regard to community mental health services and forensic psychiatry. The documents used to prepare the new document were: A Framework for the Delivery of Mental Health Services by Institutions in KwaZulu-Natal;Mental Health Services Planning Report; Strategic Policy Document for Mental Health Services in KwaZulu-Natal; Community Mental Health Services at Indlovu Region, KwaZulu-Natal; KwaZulu-Natal Health Care Act 2000; Mental Health Act 2002; World Health Report on Mental Health 2001; and Mental Health and Substance Abuse Report. The article is divided into nine sections, namely organisational structure; education, training and research; mental health ser- vice provision; highly specialised services; community mental health services; forensic mental health services; mental health and the private sector; pharmaceutical services; and summary of recommendations.


Organisational structure
The task team proposes that: • The Head of the Department of Psychiatry at the Nelson R Mandela School of Medicine be the Head of Mental Health Services in KwaZulu-Natal.
• A Directorate for Mental Health be established which will develop policy and be responsible and accountable for an efficient and effective mental health service in the province.
• A Mental Health Review Board be constituted in line with the Mental Health Care Act.This board will be responsible for the protection of human rights of mental health care users.
• District mental health committees be established to assist in the planning, implementation, co-ordination and evaluation of mental health services within the province.

Education, training and research
The task team proposes that: • An education and training structure be established by the Department of Psychiatry, Nelson R Mandela School of Medicine, to provide the necessary knowledge and skills in mental health for students, mental health personnel and consumers.This should include drawing up of protocols.
• Funding for research into mental health and mental ill health be provided by the Department of Health, KwaZulu-Natal.

Mental health service provision
The task team proposes that: • A comprehensive mental health service which is fully integrated into the general health service at the primary health care level be established.
• Appropriate management and care be given as far as possible at the lowest level of care, and where more specialised care and support is needed, it be provided at secondary and tertiary levels of care.
• The framework for the delivery of mental health services should be as depicted in Fig. 1.

Highly specialised services
Within the field of mental health certain groups of people deserve special consideration because of the unique features associated with each group.

Children and adolescents
The main emphasis must be on promotive and preventive programmes in order to prevent mental disability and to create greater mental and psychological wellbeing in each successive generation.
Where childhood or adolescent conditions do occur, then active treatment and management of such conditions must be given to prevent the risk of secondary and more serious problems in adult life.
The task team recommends that child and adolescent units be established at Pietermaritzburg and Durban, with a total of six beds in each unit for referral of all children.

Psychogeriatrics
The task team recommends that the Deputy Director for Mental Health should enter into negotiations with his/her counterpart for Chronic Diseases to clarify how and where the psychogeriatric patients will be managed.This includes filling of forms for application for a disability grant.

Intellectual disability
The task team recommends that services for the treatment and rehabilitation of severely intellectually disabled children be the responsibility of the Mental Health Services and that children with mild to moderate intellectual disability be the responsibility of the Department of Education.

Victims of violence
Intersectoral collaboration is of vital importance when trying to resolve the problems involved in violence prevention and intervention.Both the private and public sectors are involved, but a more specific policy as regards the involvement of the health component needs to be established.The Health Department, and in particular the Directorate for Mental Health, must provide the assistance and support required at all levels of care.Specialised training of mental health personnel will be required to manage this problem effectively.

Substance abuse
Substance abuse is becoming an ever-increasing problem in society.Intersectoral collaboration is essential in trying to resolve the problems associated with substance abuse.The Department of Health must take responsibility for the management of people with substance abuse as follows: •

HIV/AIDS
Intersectoral collaboration is required and the mental health sector should play a major role.In this regard active assistance in the promotion of health and prevention of disease needs to be part of all mental health programmes.

Psychosocial rehabilitation
The aims of psychosocial rehabilitation are: • To increase access to and availability of rehabilitation services to mental health users.
• To establish grounds for intersectoral collaboration in the provision of comprehensive psychosocial rehabilitation programmes.
• To facilitate planning for the prioritisation of psychosocial rehabilitation.
• To encourage the development of appropriate cost-effective psychosocial rehabilitation programmes.
• To encourage the involvement of all role players, particularly consumers, their families and communities, in the rehabilitation of people affected by mental disorders.The purpose of the task team has been to make a proposal with regard to restructuring of these services, more especially the integration of the previous apartheid structures into one functional unit.It is important to incorporate the requirements of the Mental Health Act within this service.

Community mental health services
Taking into account the vision and mission of mental health, the following aims are a priority in the delivery of community mental health: • Decrease the incidence of mental illness.
• Institute early treatment to avoid sequelae.
• Reduce functional deficits resulting from mental illness, using psychosocial rehabilitation.
• Reintegrate the patient into society.
To accomplish these aims a comprehensive, integrated service needs to be in place.This service would require involvement from all its levels of care with adequate support and referral mechanisms in place.It is imperative that input be obtained from community leaders in this process.
The aim of community mental health services is to integrate the care of a community's mental health needs with the other aspects of its health care, while at the same time ensuring that an adequate specialist support service is available to provide assistance and ongoing training to the health workers within the district health system.The primary health care service would be responsible for all initial patient contact and emergency care as well as supervision and monitoring of stable patients on long-term medication.
Given the scarcity of specialist mental health workers (psychiatrists, psychologists, occupational therapists, etc.) it will be necessary to provide the support service on an itinerant basis.The aim would be to utilise a visiting team of specialists who would see patients referred by the primary health nurse or district medical officer at the community health centre or district hospital.These patients would be booked in advance as they would be referred cases only.

Forensic psychiatric services
People who are alleged to have committed a crime and are suspected of being mentally ill should be managed as follows: • Minor crimes.These people should be screened by the local district surgeon.If found to be mentally ill they should be referred for treatment.If found not mentally ill, then justice should take its course.
• Major crimes.These people should be referred to Fort Napier Hospital.In this regard: • Local health personnel must be trained and equipped to examine and make relevant and appropriate recommendations to the court in all cases (dockets, court proceedings, social worker's report).
• All important information must be available at time of admission for observation.
• Overtly mentally disordered prisoners should be referred for treatment while awaiting trial.
• State patients.State patients comprise a major long-term residential patient load.Managing mentally disturbed criminal offenders is becoming an increasing burden on the state.
The task team recommends the following: Should the Court find an awaiting-trial prisoner to be mentally ill, the court should prove that s/he was responsible for the alleged offence before being declared a state patient.If no crime has been proved against the accused, s/he should be referred for treatment in the normal way.
Following admission, all state patients will be kept at Fort Napier Hospital for 6 -12 months (depending on the severity of the crime and/or of the mental illness).After this period active steps will be taken to prepare them for discharge should they be considered fit for discharge.In order to expedite the discharge process, these patients will be sent out on 'leave of absence' to specialised forensic units, which are nearest to their place of residence.Such 20-bed units will be established at Madadeni Hospital (northern midlands region), Ngwelezane Hospital (northern coastal region), Ekuhlengeni Care Centre (southern coastal region) and Fort Napier Hospital (southern midlands region).
To achieve effective and expeditious social rehabilitation, a policy for discharge of state patients once the underlying mental disorder is stabilised on treatment should be encouraged.Special attention to management at community health clinics and ongoing close follow-up by social welfare services should be put in place.

Mental health and the private sector
The private sector plays a vital and important role and it is important for the public and private sectors to get together in order to provide a more cost-effective and efficient mental health service (public-private partnerships).The following areas of private sector involvement must be developed: • Private practitioners.The term 'private practitioner' is used in this instance to refer to doctors, clinical psychologists, pharmacists, occupational therapists, and others working in the private sector.These practitioners have a great deal of knowledge and expertise, which could be used to assist in training programmes as well as clinical programmes in order to provide a wider service or coverage to the general population.• Industry and business could assist in mental health programmes through funding, providing services, manpower skills or other logistical support.
• Traditional healers.The possibility of collaboration between the national health care system and indigenous healers is being investigated.It is time to evaluate the strengths and contributions of the indigenous healers with a view to collaboration between the two systems.

Pharmaceutical services
A Provincial Psychiatric Pharmacy Therapeutic Control Committee should be established.Its main role will be to determine policy and procedure as regards psychotropic drugs, as well as evaluating and implementing an effective psychiatric pharmaceutical system within KwaZulu-Natal.This committee will work closely with the National Essential Drug List Committee.
It will be made up of academic and field staff from the medical, nursing and pharmacy sections.Its functions will be: • The compilation of an Essential Drug List for doctors and nurses, and the relevant review of this list on a regular basis.
• To determine policy and procedure as regards the prescribing and issuing of psychotropic medication at each level of care.
• Planning and implementing an effective psychiatric pharmaceutical system and service within the province.
This will include (inter alia) the storage, distribution and control of psychotropic medication as well as keeping of records and administrative support services.
• Liaising and co-ordination with the private sector.
• Evaluating the service on a regular basis, as well as resolving associated problems.
• Promoting information and advice on the prescribing and issuing of psychotropic medication.
• Other matters that may be referred to the Committee.

Summary of recommendations
It is recommended that: • The provision of mental health services at primary and district levels should be integrated with other aspects of health care.
• The care of acutely psychotic patients should take place at regional and tertiary hospitals.
• Each tertiary/specialised care centre should have beds for medium-to long-term care.These beds should only be for those patients who cannot be treated in the community.
• Long-term care facilities should be provided at Umngeni and Ekuhlengeni rehabilitation centres.
• Tertiary/specialised care centres should have beds for rehabilitation of patients who abuse alcohol and other substances (e.g.Newlands West Rehabilitation Centre).
• Tertiary specialised care centres in Durban and Pietermaritzburg should have a unit for child and adolescent psychiatry.
• A comprehensive integrated service should be provided with more bias towards the disadvantaged and rural areas.
• All regional hospitals should have a psychiatric unit comprising 4% of the hospital beds.
• All district hospitals should have psychiatric beds within the general wards.

No. 1
April 2004 -SAJP Mental health services in KwaZulu-Natal This article is a summary of a document prepared by a task team appointed by the Superintendent-General, Head: Department of Health, KwaZulu-Natal.The terms of reference of the task team were to scrutinise all available documents on mental health in the province and to come up with a new document entitled 'Strategic and Implementation Plan for Delivery of Mental Health Services in KwaZulu-Natal', with operational plans and time frames, and to make specific recommendations with regard to community mental health services and forensic psychiatry.The documents used to prepare the new document were: A Framework for the Delivery of Mental Health Services by Institutions in KwaZulu-Natal;

Fig. 1 .
Fig. 1.Framework for the delivery of mental health services.
Drug Abuse Rehabilitation Centres.The Department of Health in collaboration with the Department of Welfare should establish rehabilitation centres throughout the province.The identified areas are Durban, Pietermaritzburg, Madadeni and Ngwelezane.• Detoxification.One to three beds, depending on density of population, is/are required in hospitals for the detoxification of patients.• Intersectoral collaboration.The Departments of Social Development, Education and Justice and the South African Police Services should come together to fight the scourge of drug abuse.
Provision of mental health services in KwaZulu-Natal has been the responsibility of various authorities over the years.The introduc-articles Volume 10 No. 1 April 2004 -SAJP tion of new health policies during the last few years has seen an attempt to rationalise these services and bring them more closely in line with the new policies.To date very little real change has been implemented and the services remain inequitable with welldeveloped community mental health services in the urban areas and poor services in the rural areas.This state of affairs is unsatisfactory as it violates the principles of the primary health care system and is essentially a vertical service with little or no input from communities.

articles Volume 10 No. 1
April 2004 -SAJPThere should be a total of 290 beds for forensic psychiatric patients.Dangerous mentally ill patients should be referred to the national maximum security unit at Fort England Hospital in Grahamstown.

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Non-governmental organisations (NGOs).NGOs have played a significant role in mental health in South Africa, and have largely provided the much-needed support services in the communities.NGOs have distinct advantages in the delivery of services.Adequate funding and management of such funding is essential.The relationship between NGOs, communitybased organisations (CBOs) and the state needs to be established.