Mental Health Care Services in the North West Province Presentation to the Portfolio Committee Cape Town 15 March 2017

Presentation outline Background Introduction The State of Mental Health care Services in the province Package of Services Mental Health Beds in Specialised Hospitals Designated psychiatric units attached to general hospitals Private hospitals licensed to render in-patient services Units for 72-hour assessment in general hospitals Primary Health Care Services Community Mental Health Services Coordination of services Mental Health Review Board Number of deaths by year Staff establishment Budget and expenditure trends Key challenges Conclusion

Background The North West Province is South Africa’s fourth smallest province and occupies 8.7% of SA’s land area It has a population of 3.7 million (Stats SA 2011 census) This represents 6.7% of SA’s total population Shares borders with other provinces: Limpopo, Gauteng, Free State, and Northern Cape Also shares borders with Botswana to the West and North

NWP Population by District: 2016

Map of the North West showing the four districts of the province

Health service delivery platform District Health System: 4 district municipalities 19 local municipalities (sub-districts) 2 Tertiary hospitals 3 Regional hospitals 12 district hospitals 49 Community Health Centres (CHCs) 270 Fixed clinics

Introduction Mental health services in the province are provided in line with the Mental Health Act and National Mental Health Policy Framework and Strategic Plan 2013-2020 There are two specialised hospitals, two designated hospitals, two 72 hour observation units The department has also licensed three private hospitals that provide mental health services At community level the services are integrated into Primary Health Care There are no NGOs licensed to provide mental health services

The State of Mental Health care Services in the province Mental Health Services organised in line with the Mental Health Care Act (Act 17 of 2002) Two (2) mental health specialised hospitals: Bophelong psychiatric hospital Witrand hospital for intellectual disability

Witrand hospital

Psycho geriatric unit

Old Bophelong hospital

Old Bophelong hospital

Patients recreation day at Bophelong

New Bophelong hospital

New Bophelong hospital

Residential area under construction at the new Bophelong hospital

Package of Services Witrand Hospital Bophelong Hospital Intellectual disability Acute psychiatric services General psychiatry for designated status Sub-acute psychiatric services Child and adolescent psychiatry Forensic observation Psycho-geriatric services State patients Physical medicine and rehabilitation Long term/Rehabilitation services Mentally ill prisoners services Adult OPD Child and adolescent OPD

Mental Health Beds in Specialised Hospitals Approved beds Used beds Planned for new hospital Bed utilisation rate as of 3rd quarter 2016/17 Witrand 982 851 N/A 81.6% Bophelong 368 282 384 87.6%

Bed distribution by specialty at the old Bophelong hospital Service package Approved Used beds General Psychiatry Acute care 72 51 Medium term to long stay 147 120 Forensic mental health services Mental observations 10 Acute State patients 65 Medium to long stay State patients 74 36 Total 368 282

Bed distribution by speciality at the new Bophelong hospital Beds per service package No. of beds General psychiatry: 234 Acute 90 Medium-long stay 120 Long term (psycho geriatrics) 24 Forensic Psychiatry: 150 60 Medium- long stay 70 Mental Observations 20 Total 384

Bed distribution by speciality at witrand hospital Service package Number of approved beds Number of used beds Acute Physical Medicine and Rehabilitation 15 Acute Psychiatry 116 Medium to long stay 851 (Intellectual disability) 720 Chronic psychiatric patients Total 982 851

Number of beds in designated psychiatric units attached to general hospitals Name of Hospital Service package Number of beds Taung District Hospital Acute psychiatry 20 Job ShimankaneTabane (JST) Provincial Hospital 60

Taung hospital designated unit

Private hospitals licensed to render in-patient services MultiCare Hosp, Potchefstroom ( 26 beds) - Voluntary care Parkmed Hosp, Klerksdorp (60 beds) Kgatelopele Wellness Centre ( 50)

Units for 72-hour assessment in general hospitals These are units in general hospitals listed to provide 72-hour assessments to exclude physical/ medical conditions as prescribed by the Mental Health Act. Two hospitals (in addition to the two specialized hospitals) are currently listed for 72-hour assessments: Tshepong Hospital (10 beds) Mafikeng Provincial Hospital (26 beds)

Primary Health Care Services Primary Care Services for Mental Health are provided as an integral part of Primary Health Care. These would be ambulatory visits from patients either discharged from hospitals to community care or initiated on treatment within primary care. Currently mental health coordinators are appointed in 11 of the of 19 sub-districts. An ideal situation would be to have a Mental Health Coordinator per sub-district to champion the preventive and promotive aspects of Mental Health Care in the area of jurisdiction. This ideal situation has always been difficult due to shortage of personnel.

Community Based Mental Health Services Community Mental Health Services include: Community residential care (including assisted living and group homes) Day care services The province does not have any NGO licensed to provide community mental health services The initial number of beds planned for the new Bophelong psychiatric hospital was 648, however this was reduced to 384 to cater for a community component of Mental Health Services in line with mental health legislation, policy and norms. The 264 beds that were reduced from the new hospital have been allocated to different sub-districts as Community Residential facilities or Half Way Houses. The first 60 bed Community Mental Health Centre has just been completed Dr Kenneth Kaunda district. The second 20 bed facility is under construction at Boitekong near Rustenburg.

Community Psychiatric unit at Witrand

Planned community residential beds per district No. of planned community residential beds Dr Kenneth Kaunda district 122 Ngaka Modiri Molema district 98 Dr Ruth Segomotsi Mompati 94 Bojanala district 150 Total 464 A detailed breakdown of planned beds per sub-district is available

Coordination of services at provincial level The Mental Health Programme falls under the Directorate of Health programmes, and is managed at director level with all other programmes related to non -communicable diseases. The post structure has provided for three managers at Deputy and two Assistant Directors level, the latter two of who are responsible for administration of the Mental Health Review Board, and the two posts are currently vacant. The National Mental Health Policy Framework and Strategic Plan adopted by all MECs and the Minister of Health advise that all provinces should have a Directorate for Mental Health headed by a Director. This has not been possible due to budgetary constraints.

Coordination at district level The National Mental Health Policy Framework and Strategic Plan require a District Mental Health Specialist Team to be established within each district. The terms of reference for these teams is contained in the policy framework. A full team for a district has been estimated to cost around R3.5 million, but even if it is not possible to recruit all the components of a team, having some coordination and planning in a district is essential. 11 of the 19 sub-districts have mental health coordinators.

Mental Health Review Board The province has one Provincial Mental Health Review Board, which was first appointed in 2007 in line with the Mental Health Care Act requirements Composition: 4 persons that include, 1legal person, 2 Mental Health Care Practitioners and 1community member Appointed for 3 years (contracts were extended every 2 years) Current contract expires on 31 March 2017. Advertisement made on national and local newspapers, short listing and interviews conducted. Appointment letters issued, and new board members to start on 01 April 2017

Schedule of meetings of the Mental Health Review Board Members meet weekly (every Wednesday for 2-4 hrs) depending on the workload) The board caters for all 4 districts

Functions of the Board Screen all documents from all 4 mental health hospitals ( admissions, discharges, transfers, leave of absence, periodical reviews, and appeals) Conduct support visit to hospitals providing mental health services to check compliance Conduct in-service training during their visits

Number of deaths at Witrand by year Died Where 2012/13 2013/14 2014/15 2015/16 2016/17 Total Died in Witrand Hospital 28 24 26 17 19 114 Died at Potchefstroom Hospital 2 3 7 5 18 35 Died at Klerksdorp Hospital 1 Died at Tshepong Hospital Died at Baragwanath Hospital Died at Medi-Clinic Potch Died at home during weekend leave 1 (ID) 31 29 33 37 154

Number of deaths at Bophelong by year Died Where 2012/13 2013/14 2014/15 2015/16 2016/17 No date Total Died in BPH 1 5 3 11 Died at MPH 2 Died at Home 15

Causes of deaths All patients in Witrand and Bophelong died of medical conditions (details available) Monthly morbidity and mortality meetings take place and cases are discussed Depending on the need cases are referred to district and provincial patient safety group Corrective measures are taken where applicable

Clinical Psychologist Occupational Therapist Current staff establishment of Bophelong and Witrand hospitals for health professionals Hospital Category Professional Nurse Medical Specialist (Psychiatrist) Medical Officers Clinical Psychologist Social Worker Occupational Therapist Bophelong Total posts 105 2 10 9 7 1 Vacant 18 Vacant funded Filled 87 5/8 8 5 Witrand 158 3 15 13 32 6 126

Budget and expenditure trends of Bophelong and Witrand Financial Year Hospital Allocated Budget Total Expenditure Available Budget % Expenditure 2013/14: Bophelong 105,286,500 106,773,986 (1,487,486) 101% Witrand 225,276,500 242,077,345 (16,800,845) 107% 2014/15 121,096,859 114,177,275 6,919,584 94% 260,767,109 261,459,382 (692,273) 100% 2015/16 120,835,422 119,821,542 1,013,880 98% 266,318,700 263,102,827 3,215,873 99% 2016/17 142,910,175 99,217,593 43,692,582 69% 287,509,166 224,582,062 62,927,104 78%

Key challenges Inability to recruit and retain psychiatrists/scarce skills due to rurality of the province Inadequate funding affects expansion of community mental health units (half way houses) and services Infrastructural challenges

Conclusion In conclusion, the North West Department of Health believes that as the WHO defines Health as “a state of complete physical, mental and social wellbeing, and not only the absence of disease or infirmity”, for health services to be responsive to the needs of communities, mental health should be central to planning and delivery of health services.

Thank you