Enhancing Mental Health Services in KZN: Portfolio Committee Report

1. STATUS OF MENTAL HEALTH SERVICES IN KZN KwaZulu-Natal Department of Health PORTFOLIO COMMITTEE ON HEALTH 14 JUNE 2017 1

2. Mental Health Care Act (MHCA) 17 of 2002 Provides for the care, treatment and rehabilitation of mentally ill persons THUS outlining; • Procedures with admission of such persons, • The rights and duties relating to Mental Health Care Users (MHCU), • Establishment of Mental Health Review Boards, their powers and functions • Administration of the property of mentally ill persons Objective therefore is to ; • Regulate integrated, efficient and equitable access and in the best interest of MHCU at all levels of health establishments. • Chapter 10, Section 66 (o) allows for authorization and licensing of health establishments, non-governmental organizations or private bodies providing mental health care, treatment and rehabilitation services AND conditions to be attached to such authorization or license. 2

3. SERVICE PLATFORM In terms of the Mental Health Care Act, 2002 (MHCA), psychiatric and mental health services shall be provided at primary, secondary and tertiary levels of care. The appropriate model for this tiered service is as follows: • Primary level (L1): Community-based; PHC clinics and CHCs and District Hospitals • NGOs referring to PHC (Nursing personnel)and CHC (Nursing, Medical Officers and some Psychologists) and ending in District Hospitals (Medical officers, Psychologist, Social Worker, Dedicated Psychiatric and General Nurses – support from outreach Psychiatrists based in Regional Hospitals (telephonic/video-conferencing) • Secondary level (L2): Regional Hospitals • 25 bedded unit with seclusion rooms and a multi-disciplinary team (MDT) in a regional hospital • Tertiary level (L3):Specialized Psychiatric Hospitals- • Neuropsychiatry, psychogeriatric, forensic, psychotherapy, child and adolescent. 3

4. SERVICE PLATFORM The hospital platform for specialised services is comprised of 7 specialised mental health hospitals and these are; • Umgungundlovu: Townhill, Fort Napier and Umgeni hospitals • eThekwini: King Dinuzulu, Ekuhlengeni hospitals • Amajuba: Madadeni hospital • Harry Gwala: Umzimkhuluhospital 4

5. SERVICE PLATFORM Other mental health services are provided for within Regional hospitals, namely; • Uthukela: Ladysmith hospital • Ugu: Port Shepstone hospital • King Cetshwayo: Ngwelezana hospital • Ilembe: Stanger hospital • Umgungundlovu: Edendale hospital • eThekwini: Addington, King Edward, Mahatma Gandhi, Prince Mshiyeni and RK Khan hospitals. According to our STP District hospitals to cater for 5% of the total number of beds reserved for mental health care users. This is where 72-hour assessments are conducted. 5

6. TYPES OF ADMISSIONS • Acute • -Voluntary • -Emergency • -Assisted • -Involuntary • -Forensic observation, criminal capacity assessment • Chronic • Forensic; state patients and mentally ill prisoners • Rehabilitation • Step-down/ Halfway homes (NGOs) • Permanent homes (intellectually disabled)(NGOs) 6

7. ROLE OF NGOs in MNETAL HELTH • They are part of the mental health services at community level • Act as advocates for mental health care services and advocates for mental health care users • The provide support to MHCUs and their families • Provide stimulation, care and rehabilitation services for MHCUs • The provide Step-down care / Halfway homes • Act as referral gateway into health and discharge between hospital, families, SAPS, DSD and families of MHCUs 6

8. NGOs management Guiding documents in KZN • Policy for the provision of grant funding to institutions developed and approved in 2012 • Application for grant funding to health institutions formalized. • Draft guidelines for licensing community mental health NGOs in KZN developed in 2013 • Inspection tools. • NGO section criteria. • Draft Package of Services for Community Based Psycho Social Rehabilitation. • NDOH , Deinstitutionalization document 7

9. FUNDED NGOs IN KZN DISTRICTS 8

10. FUNDING RATES CRITERIA FOR NGOs as of 2015 rates • RATES FOR EACH CATEGORY 9

11. CRITERIA FOR NGO SELECTION IN KZN Interrogation and inspection of the following is conducted; • Physical structure • Care processes • Medication • Therapeutic Programs • Administration • Human resource –staff and skill mix, staff training • Monitoring and evaluation – regular check visits quarterly by District Mental Health Coordinators, audits by Provincial Mental Health Managers • Renewal of licenses – annually subject to satisfying all the above 10

12. ISSUES RAISED FROM ESIDIMENI OMBUDS REPORT A.INFRASTRUCTURE • Suitability/ not fit for purpose facilities • Space/accommodation • Access and assistive devices B. GOVERNANCE AND MANAGEMENT • Licensing • Project management –poor planning and therefore poor implementation • Managerial leadership C. FUNDING • Delayed payment of NGOs D. DATA MANAGEMENT • Monitoring and evaluation • Follow up 11

13. ISSUES RAISED FROM ESIDIMENI OMBUDS REPORT E. COMPETENCY CAPACITY ASSESSMENT • No due diligence (proven track record of NGOs) • Staffing norms, qualifications and skills F. COMMUNICATION AND REFERRALS • Non-communication with family and users re- transfers and deaths • Referral pathways inconsistent with patient lists • Right mix for right facility • Lack of coordination with district management • No proper provision for continuing with treatment plans especially medication. 12

14. STRENGTHS WITHIN THE CURRENT KZN MODEL • Annual licensing and inspection of all NGOs undertaken; • Provincial visits and monitoring conducted annually; • Grant Funding Committee to adjudicate applications is functional; • Districts monitors the NGOs quarterly; • NGOs payment linked to Finance and Budget office and the District (albeit need refining ) • Action is being taken on poor performing NGOs - some have been closed in the past • Provisional license given to NGOs that requires further compliance in certain areas • Licensing and inspections integrated with the District office, Disability and Mental health Directorates at Head Office 13

15. GAPS WITHIN OUR CURRENT KZN MODEL • Monitoring at District Level needs to be strengthened. • There is a need to increase the capacity at District coordinators level; • Need to strengthen the process of budget linked to performance – strengthen monitoring. • Strengthen information sharing between Sectors (DSD and DOH) • Need to develop a tool for tracking any new unlicensed NGO’s which are mushrooming due to financial incentives. • Increase monitoring and tracking of mortality rates in NGOs • Clarity on what our subsidy funds and what it doesn't e.g. COE, some NGOs have raised concerns that we currently just fund per patient day rate irrespective of cost to NGOs to run the service) 14

16. CHALLENGES • HR- Shortage of Psychiatrists and Psychologists in the public service • Infrastructure - Old dilapidated building not for purpose to provide mental health care • Budget - Limited budget and prioritization against burden of disease • Lack of community based services e.g. half way houses • Increase in substance abuse leading and exacerbating mental illnesses 15

17. REMEDIAL ACTION TO DATE • Finalize MOU implementation between DSD and DOH to harmonize NGO services • Work with Universities to increase training of registrars as well as retention post qualification • Working with infrastructure to cost and fund mental health facilities • To increase awareness, educate the community on early detection, treatment modalities and referral pathways • Build capacity to NGOs to co-manage and support MHCUs • Encourage active participation and involvement of family members to support families • To educate public on the dangers and prevention of substance use • Revising, updating our draft mental health strategy and costing to lobby for more budget to support mental health services 15

18. Current status of Oncology services • The full time oncologist only in Grey’s Hospital • The team of Grey’s hospital will support IALCH • 4 Rainbow oncologists (Private sector) to render service at IALCH • 25 private oncologists to provide offline planning. • Awaiting work clearance of a foreign oncologist • Permanent solution-get full time oncologist at IALCH 15

19. THANK YOU 16