Towards an integrated Mental Health Service - Health Systems Trust

Towards an Integrated Mental Health Service 

A situation analysis of the Lower Orange District 

INITIATIVE FOR SUB-DISTRICT SUPPORT 

By Natalie Grazin

ACKNOWLEDGEMENTS 

_______________________________________________________ 

I would like to thank the following people who assisted with the compilation of 

this report: 

Sister Elise Muller and Sister Katie Diergaardt, who allowed me to observe their 

practice, edited a draft of the report and gave freely of their time. 

Lesley Bamford, for her valuable advice and guidance throughout the project 

and for editing numerous drafts. 

Sister Lena Van der Westhuizen, of the Lower Orange District Management 

Team, who discussed her plans and ideas for the future of the service. 

Celia Isaacs, the head of West End Psychiatric Hospital, for information about 

the hospital. 

Peter Barron, who gave advice and edited various drafts. 

All the nurses from the primary health care clinics and the hospitals who 

participated in the focus group discussions. 

Lauren Muller, for bringing her insight of the national context to her editing of 

the draft and for her guidance in developing the project plan. 

Andy Gray for advice about nurse prescribing.


CONTENTS 

Executive Summary 

ii 

Introduction 1 

Chapter 1: Background 2 

1.1 History of the service 

1.2 District Development 

1.3 Socio-economic context 

Chapter 2: Psychiatric Facilities and Services 6 

2.1 Inpatient services 

2.2 Upington psychiatric outpatients clinic 

2.3 Psychiatric outreach clinic service 

2.4 Service to outlying areas (“postal service”) 

2.5 Psychiatrist 

2.6 Psychologist 

2.7 Forensic patients 

2.8 Child and adolescent mental health 

2.9 Elderly mentally ill 

2.10 Learning disability facilities 

2.11 Drug and alcohol services 

2.12 Crisis/emergency service 

2.13 Certification of Involuntary patients 

2.14 Health promotion activities 

2.15 Inter-sectoral work 

2.16 Other community structures 

Chapter 3: Key Issues and Problems 17 

3.1 Prescribing 

3.2 Relations with other district health care providers 

3.3 Lack of district inpatient facilities 

3.4 Lack of information 

Chapter 4: Integration of Mental Health into PHC 24 

4.1 National and local context 

4.2 First steps 

4.3 The role of the district 

4.4 The role of the psychiatric nurse practitioner 

4.5 Management and accountability arrangements 

4.6 Project plan 

Chapter 5: Strategy for Future Development 42 

Appendix 1: Patients registered with psychiatric service by locality 49 

Appendix 2: PHC clinics represented in the nurses’ focus group 53 

i


EXECUTIVE SUMMARY 

Since 1994, the direction of national policy has been towards the integration of 

mental health services into the primary healthcare system, thus ending years of 

segregation and stigmatisation of psychiatric patients. National policy also 

envisions the development of psychiatric services so as to reflect a broader 

definition of mental health, incorporating preventive activities and substance 

abuse services. 

The adoption of these policies brings South Africa into line with the many 

countries around the world who have attempted to re-integrate psychiatric 

patients into the community over the past fifteen years. However, the 

experiences of countries such as the United States and Britain have 

demonstrated the dangers of attempting to undertake community integration 

too fast and without ensuring that sufficient resources and skills exist within the 

community. 

This paper is the result of research which set out to consider the feasibility and 

implications of implementing these policies within the Lower Orange district, 

given the plans of the District Management Team (DMT) to integrate psychiatric 

services into primary health care (PHC) as of the 1 st April 1999. A rapid 

situation analysis was carried out during October 1998 by means of informal 

interviews, focus group discussions and analysis of existing data. 

The research found that: 

• Despite a paucity of resources compared to national and international 

norms, Lower Orange’s limited psychiatric service is robust, accessible and 

patient-friendly. 

• Mental health services within Lower Orange remain primarily curative in 

nature and follow a traditional “psychiatric” model; wider mental health 

services are yet to develop. The need for a psychologist is acutely clear. 

However, there is widespread enthusiasm for the introduction of activities 

aimed at preventing the onset of mental health problems. A schools 

education programme and community education are locally regarded as an 

urgent priority. 

• Psychiatric services are still organised vertically from Kimberley; for these 

services to be led by the local DMT and involve the local community will 

represent a large shift in culture and focus 

• At present, there are many logistical issues which hamper the provision of 

an effective service within the district. Such issues include problems with 

the availability of drugs, transport problems and the reliance upon a 

psychiatrist who services the entire population of the Northern Cape. 

• Data collection is inadequate and is not translated into valuable information. 

There is also a paucity of information about the mental health profile of the 

ii


district which makes effective strategic planning and targeting of services 

impossible. Existing data suggest a worryingly high number of attempted 

suicides at around eight per week in Upington alone. 

• There is strong support in principle amongst primary health care staff for 

the integration of psychiatric care into primary health care clinic services. 

However, many have concerns about their capacity (in terms of time) to 

manage the extra workload without compromising patient care. There are 

also widespread concerns that some primary health care staff lack the 

knowledge, skills and confidence to undertake care of psychiatric patients. 

• As psychotropic drugs are categorised as Schedule 5, there will be major 

difficulties in delivering the psychiatric service from PHC clinics without a 

change in the regulations which currently prevent PHC clinics from stocking 

Schedule 5 drugs. 

• Amongst key role players within the district, there are widely differing 

visions of how far services need to change. No shared concept of “an 

integrated service” has yet emerged. 

The key recommendations of the paper include: 

• The formulation and agreement of a district strategy and timetable for the 

gradual integration of mental health services into PHC 

• The re-consideration by the DMT of the 1 st April deadline in order to ensure 

that neither patient care, nor the safety of the community, is compromised; 

a staggered approach to integration may better safeguard the quality of 

care 

• A comprehensive training programme for all primary health care staff within 

the district to equip them to deal with psychiatric patients 

• Training of the DMT to prepare for the strategic management of the service, 

including the supervision, monitoring and evaluation of the service 

• Community involvement in shaping the future configuration of services so as 

to gather opinion and explain the notion of “care in the community” 

• A re-examination of the role of the provincial psychiatrist within the district 

• Investigation of the feasibility of rendering secondary level (inpatient) 

psychiatric care within the district, potentially within Gordonia Hospital, with 

the aim of managing the vast majority of patients without referral to 

provincial services 

• Research to establish the extent and nature of mental health needs of the 

local communities so as to facilitate an informed approach to service 

planning 

iii


• A community education programme involving key role players such as 

teachers and church leaders aimed at reducing substance abuse and suicide 

rates 

The implementation of national policy will thus entail an immense amount of 

work. However, the district is rich in human resource capacity and there is 

overwhelming support for the principle of integration. If approached with due 

care, the reconfiguration of services represents an opportunity for Lower 

Orange to develop a modern, high quality service. 

iv


Introduction 

Psychiatric services in the Lower Orange region have traditionally operated in 

an isolated manner, divorced from other healthcare providers within the district. 

The 1995 White Paper, Transformation of the Health System, emphasised the 

urgency of developing traditional, curative psychiatric services into a broader 

concept of mental health, and secondly, the importance of integrating mental 

health services into the new, primary-care led district unit. 

The Northern Cape Provincial Department of Health is working towards 

devolution of the care of psychiatric patients to the district level. For the 

district management team of Lower Orange, this will mean devolving care to 

the PHC teams; this transfer process is tentatively planned to begin as of 1 st 

April 1999. This process will have considerable implications for the PHC staff, 

for psychiatric nursing staff and of course, for the patients and their families. 

Objectives 

This paper provides: 

• a detailed account of the nature and functioning of psychiatric services 

within the Lower Orange region 

• an analysis of the key issues and problems facing the psychiatric service 

• a suggested list of steps necessary before 1 st April 1999 if the integration of 

psychiatric services into PHC is to be successful 

• an action plan to address the priorities for the development of the current 

psychiatric service into a broader mental health service 

Research methods 

This study was carried out through interviews with the following healthcare 

staff: 

• the two nurses currently providing the psychiatric service; 

• the Chief Professional Nurse at district level responsible for PHC; 

• nursing staff from Kakamas and Upington hospitals 

• a focus group of PHC nurses from around the district (details of participants 

in Appendix II). 

1

1.1 History of the service 


Chapter 1 

Background 

Community Mental Health services within the Northern Cape are still organised 

at a provincial level, utilising a classically “vertical” management style. The 

service has until recently been managed from Kimberley, with clinical, 

budgetary and operational issues all relating directly up from Lower Orange to 

Provincial level. Between 1997 and 1998, some progress has been made in 

increasing the operational and budgetary elements of the service’s 

management down to the district management team. The salaries of personnel 

working within psychiatric services have for example been paid by the district 

office rather than by the Provincial office for the first time. However, the 

ordering of all supplies such as drugs and stationary is still administered 

through Kimberley. Clinically, the service maintains its orientation directly 

“upwards” to the Provincial centre and thus remains fundamentally distinct from 

other district health services. 

The Northern Cape suffers from a severe paucity of resources and services 

within mental health. There is only one inpatient facility for the entire Province, 

at the West End Hospital in Kimberley. The Upington clinic is one of only two 

psychiatric outpatients clinics throughout the province; the other is located in 

De Aar, in the Lower Karoo region. The Kalahari region, Namaqualand region, 

and the Hantam region have no psychiatric service personnel at all. For most 

patients within the province, their only contact with the psychiatric service is an 

annual consultation with a psychiatrist. A system operates by which psychiatric 

drugs for named patients are posted from Kimberley and distributed by PHC 

nurses. Over the past two years, progress has been made in Namaqualand in 

rendering psychiatric services from within PHC facilities. 

The psychiatric clinic in Upington was established in the early 1980s. Until that 

time, the psychiatrist based in Kimberley offered a service by which 

patients could have psychiatric drugs posted directly to their homes. Sister 

Muller took up the post of Psychiatric Nurse Practitioner in 1986 and worked 

initially with an enrolled nurse. A second post, also at Nurse Practitioner level, 

was created soon after her appointment and has been filled by a number of 

people. Sister Diergaardt took up the post in 1991. The clinic now has almost 

700 patients on its register, 500 of whom live in or around Upington, and the 

remainder being patients from Keimoes, Kakamas and Kenhardt. Sister Muller 

is a Chief Professional Nurse and Sister Diergaart, a Senior Professional Nurse. 

A map overleaf shows the distribution of mental health service facilities within 

the province which serve the Lower Orange district. 

2


MAP OF MENTAL HEALTH SERVICES WITHIN 

THE NORTHERN CAPE PROVINCE SERVING LOWER ORANGE 

3

1.2 District Development 


The Lower Orange region is operating to a large extent independently as a 

district unit. It has a full DMT in place which occupies a dedicated office which 

is well equipped to allow the team to take full responsibility for the running of 

its services. Well developed financial management systems are in place. 

Within the district, clinical services are gradually and appropriately being 

transferred down from provincial level. Along with mental health, oral health is 

identified as one of the few services which has not yet been integrated into 

district level PHC provision. 

1.3 Socio-economic context 

There are several socio-economic factors which influence the mental health 

profile of the region. The first is the agricultural base of the local economy, 

which produces grapes, sun-dried fruits and wine. The wide-scale availability 

and extremely cheap price of locally-produced alcohol means that alcohol 

misuse is a common characteristic of patients who develop mental health 

problems. The extent of alcohol availability is exacerbated by the “dop 

system”, by which agricultural workers receive a proportion of their wages in 

the form of wine. It is thought that this system is still in use within the district. 

Research suggests that the correlations between alcohol abuse and psychiatric 

disorders are significant: “alcholics” are 21 times more likely to have a diagnosis 

of anti-social personality disorder compared with non-alcoholics; 6.2 times more 

likely to have a diagnosis of mania; 4 times more likely to have a diagnosis of 

schizophrenia; and 1.7 times more likely to have a diagnosis of depression. 1 

Should these correlations hold true within the South African context, the 

consequences for mental health in Lower Orange would be considerable. It was 

certainly the opinion of all healthcare professionals who participated in this 

research that alcohol misuse is indeed a prime cause what appear to be high 

levels of mental ill-health within the region. 

The second factor affecting mental health within the region is the high level of 

unemployment. The 1996 Census found that the Northern Cape has an 

average unemployment rate of 29%. This is only a small improvement upon 

the October Household Survey of 1994, which estimated that 32,5% of 

economically active people were unemployed. The 1994 survey also found that 

unemployment rates were higher for Coloureds (37,9%) and Blacks (39,4%) 

than Whites (7,2%). Fifty-seven percent of unemployed people had been 

unemployed for more than a year at the time of the survey. 

Benefits, pensions and other grants therefore form an important source of 

income for many households. Although there are no accurate figures, there is 

no doubt that a sizable proportion of the population live in poverty. 

1 Helser J.E. and Pryzbeck T.R. (1988), The co-occurrence of alcoholism with other psychiatric disorders 

in the general population and its impact upon treatment, Journal of Studies on Alcohol, 49, 219-224 

4


Finally, there is a strong seasonal variation in availability of work. During 

November and December, many hundreds of migrant workers come into the 

area and live temporarily on the farms at which they are working. These 

workers represent an increasing, if small, proportion of individuals presenting to 

the psychiatric services. Their problems are exacerbated by language 

difficulties and by the absence of a family or other social network to support the 

patient and ensure compliance with medication. 

5


Chapter 2 

Psychiatric Facilities and Services within Lower Orange 

2.1 Inpatient services 

There are no psychiatric inpatient facilities within Lower Orange itself. The 

Northern Cape has just one designated psychiatric hospital, the West End 

Hospital located in Kimberley, which is around 400 kilometers from Upington. It 

has 107 beds, of which around 36 are dedicated to long-term patients with who 

have become institutionalised within the hospital and cannot be transferred out 

into the community. The remaining 70 beds are for patients experiencing 

periods of acutely mental illness. This number is however significantly lower 

than it was some years ago following the closure of wards and a gradual 

reduction in the number of beds over the past few years. The hospital can 

therefore offer only limited support to the Lower Orange region. Furthermore, 

the psychiatric nurses within Lower Orange have increasingly attempted to 

manage patients within the community; numbers of patients referred to 

Kimberley have decreased significantly over the past ten years. The district 

hospital, Gordonia, is located within Upington and provides secondary level 

services. It does not however accept psychiatric patients on a routine basis. 

The primary advantage of the West End Hospital over community care is that it 

can provide a high level of observation and on-site medical attention from a 

medical officer each day and from the psychiatrist when he is in Kimberley. 

Patients also have limited access to rehabilitative services such as 

physiotherapy and occupational therapy. The hospital has however 

experienced great difficulties in attracting and retaining a psychologist; this post 

is currently vacant. There are also facilities for the use of ECT as a last resort 

therapy. However, the psychiatric nurses in Upington report that it is a 

depressing and restrictive environment which itself does little or nothing to 

promote good mental health. 

The DMT in Lower Orange believe that some of the budget for psychiatric 

services within their region is still allocated to the West End Hospital. Clearly, 

there will continue to be some allocation of Lower Orange funds as long as the 

hospital provides some service to Lower Orange residents; however, given the 

gradual reduction in the utilisation of inpatient services at Kimberley, there is 

need to review the allocations to each sector of the service and if necessary, to 

negotiate adjustments as appropriate. 

2.2 Psychiatric Clinic, Upington 

The clinic is located in a dedicated building in the centre of Upington and is 

therefore convenient for patient access. It is, however, slightly set back from 

the road and the entrance is quite discreet, affording a degree of 

confidentiality. 

6


The clinic is made up of six rooms, all leading off one corridor. The first is used 

as a patient waiting room; the second as an office, although it appears to be 

used only rarely; the third contains the drug cupboards and the filing cabinets 

containing the patient records and is consequently the location for the majority 

of patient visits; the fourth is used by the psychiatrist during his six monthly 

visits; the fifth is used as a general store room, including the boxes containing 

used sharps (see below); and the sixth as an additional waiting room during the 

psychiatrist’s visits. 

The space available to the clinic therefore appears to be more than ample, with 

some rooms going unused for the vast majority of the time that the clinic is 

open. However, the level of privacy afforded to patients both in the waiting 

room and during consultations is minimal and the environment is not conducive 

to patient disclosure of sensitive issues or discussion of a patient’s problems. 

For reasons of safety, the nurses keep the doors of the rooms in which they are 

seeing patients open at all times. 

The clinic effectively runs an open access service, although a form of 

appointment system exists insofar as patients are expected to present on a 

regular date within each month. No exact time within the day for their 

appointment is stated. In practice, however, the service runs as an open 

access facility: patients know that they can turn up at any time and see the 

sisters (for example, on the day before the clinic was visited, Monday 5 th 

October, 21 “appointments” had been made but 38 patients were seen 

altogether). There were 499 patients on the Upington register at the end of 

September. Details of monthly attendances are given in Appendix 1. 

Patients present with any form of query or problem, or if they want advice 

about anything. The scope of such questions extends beyond concerns related 

directly to mental health, and even beyond concerns related to patients’ 

physical health; many patients also come in with questions about disability 

benefit, housing and so on. It should be noted that many of the service’s 

patients will present firstly to the two psychiatric nurses with complaints such 

as a cough or other chest complaints, rather than to their local PHC clinic. This 

is simply because the service is one which is welcoming and reassuring, it is a 

service with which they are familiar and is easily and rapidly accessible with 

little waiting time. The two psychiatric nurses will then refer the patient to their 

local PHC clinic. The only physical examination that they will carry out 

themselves is to measure patients’ blood pressure. Usually, they will give the 

patient a referral letter which will let the PHC staff know that this is a patient of 

theirs and giving details of the medication which the patient receives so that 

PHC nurses will recognize side effects as such and not as symptoms which in 

themselves require treatment. 

Processes 

The Upington clinic is open to patients from 7.30am until 1pm and 2pm to 4pm 

Monday to Friday, except for the three days a month that an outreach 

psychiatric service is offered in Keimoes, Kakamas and Kenhardt. Between 2pm 

and 4pm, the nursing staff complete a number of duties within the clinic: 

7


• Making up new files 

• Completing requisition forms for the supplies of drugs, syringes and other 

sterile equipment, appointment cards and new files 

• Topping up the drugs cupboard and checking the records of drugs already 

distributed against quantity of drugs remaining in the cupboards 

• In the week before the psychiatrist’s visit, all 500 sets of medical records 

must be prepared with a written up prescription 

In addition, patients do come into the clinic for their appointments during the 

afternoon despite the fact that they are discouraged from doing so. 

On Monday afternoons, the nurses take an outreach service to: 

• Individual disabled patients in their homes within the Upington area 

• Old age homes and nursing homes within the Upington area 

• Upington prison (1 st and 3 rd Monday of each month) 

• House visits to assess families within their own environment 

• Suicide attempt counselling for patients admitted to Gordonia Hospital 

An appointment with a new patient will take between 1 to 11/2 hours. In this 

appointment, at which both nurses are present, a full medical history from birth 

is taken. The nurses strongly encourage patients to bring a family member 

with them so as to capture as much information as possible at this stage. The 

nurses state that they search in this initial interview for any possible physical 

cause of the patient’s behaviour such as head injury or severe hyper-tension. If 

a physical cause is found or suggested, the nurses refer the patient back to 

their local PHC clinic with a letter explaining that this patient is not 

psychiatrically ill. On the rare occasion that a serious organic illness is found, 

patients are referred immediately to Gordonia casualty. 

New patients are called in for a follow up appointment one week after their 

initial appointment, primarily to determine whether the medication is working. 

Once the patient is stabilised, monthly appointments for medication take 

between 5 and 10 minutes, depending on whether the patient has any 

problems or complaints. 

A full report is written into the notes at every appointment, however cursory 

the patient’s visit. Patients are always asked if they have experienced any 

problems over the past month and if they feel well. 

Language 

Ninety percent of the nurses’ dealings with patients are in Afrikaans. They 

report that a handful of their regular patients speak only Xhosa or Tswana. If 

these patients do not bring with them a family member or neighbour who can 

translate for them, the nurses go out into the street and will ask the first person 

who can translate to do so for them. The number of patients with whom there 

is language barrier is increasing as the numbers of seasonal workers migrating 

into the area from Kuruman increases each year. 

8

Collection and use of Iinformation 


Unlike other areas of the country, the psychiatric service in Lower Orange is not 

required to collect data regarding the diagnoses of the patients on their register 

or even to break down their attendance figures into basic categories of mental 

illness. For example, psychiatric outpatients clinic at Mary Theresa hospital in 

Mount Frere records diagnoses within their register, which allows a profile of 

mental illness within the region to be produced within the following basic 

categories: 

• Schizophrenia 

• Toxic psychosis 

• Depression 

• Senile dementia 

• Mania 2 

Unfortunately, no such information is collected in Lower Orange, and 

consequently, no analysis of data is carried out to provide information which 

might inform the planning of health services. The raw data does exist as a 

diagnosis within each patient record and can consequently be gathered by 

extracting the information from each of the 700 records. This exercise was 

carried out in October 1998; the results are given in section 3.8. 

Confidentiality 

At the start of their visits to the psychiatric nurses, patients sign a consent form 

with regard to the confidentiality of their records and details. The form permits 

access to the records for “all the members of a multi-disciplinary team directly 

involved in medical care”. This facilitates communication between psychiatric 

service staff and other healthcare professionals, particularly PHC nurses. 

Safety and Security 

The two nurses aim to see all patients together, i.e. if possible, both nurses are 

present in the room during each and every patient visit. This is primarily for 

reasons of safety. New patients are never seen by one nurse alone until their 

assessment is complete and the nurses have established whether the patient 

has a tendency to be violent, aggressive or unpredictable. 

If a patient to whom the nurses are supposed to give medication is recalcitrant, 

they will in the last resort call the police to pin him (occasionally her) down 

while an injection is given. 

As the nurses spend a large part of each day giving injections to potentially 

violent and aggressive patients, it is perhaps not surprising that they sustain 

needlestick injuries fairly frequently. This obviously exposes them to the risk of 

infection with any diseases carried by their patients; they report being exposed 

2 Jones L (1998) Mental Health Services in Mount Frere Sub-District, Initiative for Sub-District Support, Health Systems Trust, 

Durban 

9


to the blood of patients known variously to have syphilis, drug-resistant TB and 

Hepatitis. 

In the event of a needlestick injury, the two nurses follow a procedure which 

they have created for themselves and which is not written down. The most 

recent guidelines for action following exposure to blood of which they have a 

copy were published in 1992 and obviously make no reference to prophylactic 

drugs for HIV. In fact a Northern Cape provincial protocol for post-exposure 

prophylaxis (PEP) was published in April 1998 and Gordonia Hospital has a 

copy, but it does not appear to have filtered down to the nurses. 

The procedure followed by the two psychiatric nurses is as follows: 

1. If possible, they take a blood sample from the patient and take it to the 

laboratory at Gordonia Hospital for rapid testing. 

2. The nurse involved receives limited (minimal) HIV pre-test counselling and 

discusses the potential need to embark on a course of PEP treatment 

(presumably with a combination of AZT and 3TC, although this is not clear). 

3. They complete a report on the incident which is given to the Chief 

Professional Nurse at district level with responsibility for Primary Health 

Care. 

4. If the results of any tests on the patient’s blood should be positive, the 

nurses commence treatment as appropriate. 

As the blood tests for HIV have proved negative each time, neither of the two 

nurses has ever had to take PEP for HIV. They have however both taken drugs 

following the positive patient blood tests for other diseases such as syphilis. 

The two nurses appear to have developed a very good working relationship 

with the laboratory staff at Gordonia to facilitate this arrangement. 

The other area of concern with regard to the safety of both nursing staff and 

patients is the lack of adequate facilities for disposal of sharps. The clinic 

possesses two, very small sharps bins of the sort which are intended to be 

thrown away intact, container included. As this is all they have, however, the 

two nurses simply empty their contents when full into cardboard boxes which 

are stored in an open room at the back of the clinic. When a number of full 

boxes have accumulated, the nurses take the boxes up to Gordonia Hospital for 

disposal. 

The danger of having a large number of used syringes accessible within the 

clinic is considerable, especially as the clinic’s patients are potentially and 

occasionally aggressive. Although the room in which they are kept is 

theoretically off limits to patients, there is little to stop them wandering into the 

room. This is most likely in the weeks when Mr Piotrowski, the psychiatrist, is 

present, when up to 80 patients together with their relatives pass through the 

clinic, some waiting in an additional waiting room adjacent to the store room in 

which the used sharps are stored. 

In the interests of the safety of both staff and patients, efforts should be made 

to provide improved facilities for the disposal of sharps as soon as possible. 

10


Defaulters 

At the end of each month, the nurses check through the diary to establish 

which if any patients have not presented for the medication during the month. 

Once a period of over 2 months elapses without a patient visiting, the nurses 

will make attempts to contact the patient or their family; to this end, they either 

write to the patient, or more commonly with the majority of the patients who 

live in or around Upington, they will visit the patient’s home. If a patient is not 

traced after three months, their file is moved to a separate filing cabinet for 

“Defaulters”, until such time as he or she may re-appear. 

If a patient plans to leave the area, the nurses will write a referral letter for the 

patient to take with him/her. More commonly, patients leave the area at short 

notice and cannot be traced. It is quite common for the nurses to receive 

phone calls and letters from psychiatric services in the rest of the country 

reporting on the presentation of one of their missing patients. To facilitate this 

communication, all patients of the psychiatric service possess an appointment 

card on which the phone numbers of both the Upington clinic and the West End 

Hospital are given, and this is how contact between clinics is facilitated. The 

card does not give details of diagnosis or medication, but simply the date of the 

patient’s next appointment. The cards are supplied by either West End Hospital 

specifically or Kimberley Hospital (non-psychiatric) and are standard outpatient 

appointment cards. The cards are ordered every month as a standard 

requisition; the nurses report that they generally order 100 and receive 50. 

2.3 Outreach Clinic Service 

The two Sisters provide an outreach service to three local areas: Keimoes, 

Kakamas and Kehardt. They travel to the these areas by car once a month and 

see during this time all the patients who live in these areas for the monthly 

medication appointment. Numbers of patients seen at these clinics are given in 

Appendix 1. 

The monthly outreach psychiatric service offered in Keimoes, Kakamas and 

Kenhardt is located within the PHC clinic in each town. It is not known how 

adequate facilities are in these clinics to cope with an additional outpatients 

service going on during normal clinic hours. There are also considerable 

concerns regarding patients’ confidentiality within this arrangement, as 

psychiatric patients are seated within the same waiting area as all other 

patients but are called to a clearly distinct service. 

2.4 Service to outlying areas (“postal service”) 

Patients from other outlying areas to which the District council provides services 

are initially referred to the Upington clinic for diagnosis and the first stages of 

care. They are treated at the Upington clinic for the first three months, after 

which they transfer, if stable, to the care of their local PHC clinic sisters. These 

areas, in which there is no outreach psychiatric service, are supplied with 

11


psychiatric medications by a “postal” service, by which medications are posted 

from Kimberley to PHC clinic nurses, who distribute these to the patients. 

These patients are the most likely not to keep their yearly appointment with the 

Psychiatrist. The usual practice is for the nurses at each PHC clinic to escort 

the group of patients from the area to Upington. In practice, however, the 

group consists primarily only of those patients who have been experiencing 

difficulties with medication or who have relapsed, as the journey is a long one. 

This results in patients being taken off the register if a period of more than two 

years elapses without their having seen the psychiatrist, as it is illegal for their 

medications to be prescribed only by a nurse without the supervision of a 

psychiatrist once a year. 3 

It is not known how many patients receive their psychiatric care in this manner; 

figures would presumably be held in Kimberley. 

3.1 The Psychiatrist 

The psychiatrist to the Lower Orange region (in fact, to practically the whole of 

the Northern Cape Province) is Mr Piotrowski. He appears to spend much of his 

time travelling to the 51 different local clinics which fall under his jurisdiction. 

Within the Lower Orange region, he runs outpatients clinics at which he sees all 

the patients on the nursing service’s register. These clinics are run: 

• for three days at Upington, every six months 

• for one day each at Keimoes, Kakamas, Kenhardt, Pofadder, Boegoeberg 

and Grobelershoop once a year 

The main purpose of these visits is firstly to see new referrals and secondly to 

allow the psychiatrist to sign off and approve the medication prescription of 

each patient as recommended by the psychiatric nurses. This latter task is 

necessary, according to all the nursing staff interviewed, because it is a legal 

requirement that patients taking psychiatric drugs be seen at minimum once a 

year by a psychiatrist; without this, ongoing nurse prescribing is illegal. 

Consequently, the psychiatrist sees a large number of patients in a very short 

time span; at Upington, the numbers are of necessity around 70-80 patients a 

day. Although it is frowned upon by Kimberley, the psychiatrist also makes 

visits to the old age homes within Upington, rather than demand that these 

patients come to the clinic. 

Mr Piotrowski does not have a cell phone; therefore, when questions arise, the 

nurses waste many hours calling around the local clinics throughout the 

Northern Cape in an attempt to trace him amongst the local clinics within the 

locality that he is known to be visiting. Such queries however arise 

infrequently; only when they are uncertain with regard to the prescription of a 

drug for a patient who also has an existing organic disease do the nurses 

consult their psychiatrist. 

3 It is not clear what the source of these prescribing regulations, why this supervisory role could not be 

undertaken by a local doctor rather than a psychiatrist specifically and whether the notion of a yearly 

medical consultation remains the legislative basis. 

12


Mr Piotrowski has a Medical Officer working with him who should eventually 

lighten the burden upon him as an individual and act as an alternative source of 

advice to the nurses. At present, however, she is very new and is not in a 

position to advise the nurses as this is her first post within psychiatric medicine. 

2.5 Psychologist 

There is a private clinical psychologist within Upington but no state psychologist 

throughout the entire province apart from one who works solely at the West 

End Hospital. Nursing staff within Lower Orange felt this to be one of the 

greatest weaknesses of the service they offer. 

2.6 Forensic patients 

Forensic patients who need observation (4/5 a year) are referred out of the 

Province to Valkenberg, a psychiatric hospital in Cape Town. This is a legacy 

from the days when Valkenberg provided a service to the whole of what was 

then the Cape Province. There has long been talk that this will eventually 

change and that forensic patients will go instead to Bloemfontein. The nurses 

rarely receive further information or feedback about patients who have been 

admitted to Valkenberg once they return to the community; indeed, they do not 

necessarily know that such patients have returned at all. 

2.7 Child and Adolescent Mental Health 

Both adult and child/adolescent care is undertaken by all the providers of 

psychiatric care in the region; there are no dedicated acute or community 

psychiatric services for this client group. The provincial education department 

has two psychologists for school age patients but they deal primarily with less 

severe learning disabilities and the education system is ill-equipped to deal with 

children with disruptive behavioural disorders. The provincial Department of 

Education reports that many schools simply refuse to include such children in 

their classes and that their schooling often ends at this point. 

2.8 Elderly Mentally Ill 

There are no specialist services available for this client group. Patients with 

senile dementia are seen by the psychiatric nurse practitioners. 

2.9 Learning Disability facilities 

Two schools for children with combined learning and physical disabilities exist 

within Kimberley, but have only 45 places between them and clearly cannot 

therefore provide for all the children within the entire Northern Cape Province 

who require such a service. In any case, neither has provision for children to 

board, and they cater therefore solely for children from Kimberley itself. Most 

children with learning disability from Lower Orange therefore remain at home 

and may or may not attend school. 

13

2.10 Drug and Alcohol Services 


No state facilities for rehabilitation exist. Private hostels for substance users 

seeking treatment are available but are outside the financial capacities of most 

Lower Orange families. 

2.11 Crisis/emergency service 

The region has does not possess the capacity to provide this level of service. At 

present, the service is officially an “office hours only” service, although the 

psychiatric nurse practitioners do receive phone calls at home during the night. 

These calls are most frequently from the Casualty departments of the region’s 

hospitals, and their purpose is generally to find out whether a patient who has 

arrived at Casualty and is displaying behaviour suggesting mental illness is 

already a patient known to the psychiatric service and if so, what medication 

they are already receiving. Such patients are usually kept overnight in hospital 

and sedated until the psychiatric nurses can visit them the next day. 

When known patients of the service are involved in criminal activity, the police 

will call the psychiatric nurses the next morning to let them know that the 

patient has been detained. On the occasions that a patient is so aggressive or 

violent overnight or during the weekend that they cannot be managed within 

the community, the family will request the police to detain them in the police 

cells and the nurses will be called in to see them the next day or Monday 

morning. This situation is obviously far from ideal. 

2.12 Certification of Involuntary patients 

Under the 1973 Mental Health Act, patients who will not voluntarily enter 

inpatient psychiatric care can be “certified” under Section 9 and compelled to 

do so. A patient’s certification must be agreed by two doctors, who may not 

work within the same practice. 

This legislation is invoked only rarely within the Lower Orange Region, although 

cases do occasionally end up at the Upington magistrates court. The nurses 

make every attempt to stabilise the patient with the range of drugs available to 

them in Upington and to keep the patient within the community rather than 

send them to Kimberley. Should improvement however not be achieved, the 

only circumstances in which such a drastic measure is taken by the psychiatric 

nursing staff are: 

• That the patient is a serious danger to themselves and is highly likely to 

self-harm unless under close supervision; and, that there is no-one (such 

as family) able and willing to undertake such a supervisory role 

• That the patient represents a real danger to others and cannot be allowed 

to remain within the community in the interests of others’ safety 

The numbers of Lower Orange patients referred to West End, whether 

voluntarily or involuntarily, has reduced significantly over the past ten years; 

14


only a handful of patients are now referred each year, of whom five to seven 

will be certified under Section 9 of the Mental Health Act. The nurses report 

that they now care for the vast majority of patients within the community; of 

those who are referred, a much lower number than ten years ago are 

schizophrenic, while the number of patients with bi-polar mood disorders who 

need referral has increased. 

2.13 Health promotion/prevention activities 

The psychiatric nurses reported that they had made a few tentative ventures 

into preventative work. One was in 1995, when they participated in a “Health 

Week”: they spoke to groups of high school pupils who were bussed into a 

stadium in which they received education on various aspects of health. A 

number of referrals had stemmed from that experience, suggesting that there 

was a significant number of teenagers for whom education was the prompting 

they needed to come forward with their problems. Following the Health Week, 

one school actually invited the psychiatric nurses directly to run a number of 

sessions with their pupils; however, the process was not repeated the next 

year. Many nurses agreed that individual schools would not be prepared to 

organise workshops around alcohol or dagga abuse for their pupils because 

they feared it would reflect badly upon the school. It was felt that less attention 

had been given to these issues since the posts of dedicated school nurses were 

abolished some years ago. 

2.14 Inter-sectoral work 

Criminal justice system 

When patients need to appear in a criminal court as defendants, the two nurses 

can be asked to give evidence, and are on occasion, subpoenaed by the courts 

against their patient’s wishes. In such circumstances, they state merely that 

the defendant is a patient of theirs and that they prescribe medication for him. 

If a patient wishes their lawyer to have access to their medical records, they 

sign a form giving a named individual permission to access the records. 

Correctional Services 

The psychiatric nurses run a clinic session within Upington Prison twice a month 

for around two hours at which they see between 18 and 25 patients. As 

Upington prison has recently been upgraded to a maximum security prison, 

some of their short-term patients have been transferred to Springbok and 

Kimberley, and a new group of inmates requiring psychiatric treatment has 

arrived. 

Welfare Department 

The psychiatric nurse practitioners have frequent dealings with the social 

workers, to whom they refer many of their patients. This is most commonly 

15


with regard to housing and to disability benefits; however, they report that 

almost all of their patients face significant socio-economic problems. They are 

also involved in their patients’ applications for Disability Grant. Initial 

applications must be signed by the psychiatrist, but further applications for 

continuation of the grant may be signed by a Psychiatric nurse. The two 

Upington nurses are not aware of any national or district policy regarding the 

“level” of illness which qualifies someone to receive Disability Grant; they follow 

the guidelines used by Mr Piotrowski, which are that a patient should have been 

on medication for six months and still not be in a position to return to work. If 

this policy differs from that used by other healthcare professionals within Lower 

Orange, it may be necessary to bring some consistency of approach to the 

issue. 

2.15 Other community structures 

Traditional Healers 

A review of mental health services in the Mount Frere area highlighted the role 

that alternative and traditional healers played in the community’s response to 

mental health difficulties and argued that collaboration with traditional healers 

is an essential step in ensuring that patients requiring mental health care are 

brought to the psychiatric services. 

This analysis appears to hold true for the Lower Orange area; however, given 

the large coloured population of the district, the forms of traditional healers to 

whom the community turns are very different from those in the Mount Frere 

region. 

Many coloured families take their relatives to the “smeer-ouma” or to other 

traditional healers before accepting a referral to Western-style health facilities. 

The psychiatric nurses recalled an occasion on which one smeer-ouma had 

actually accompanied a woman to the psychiatric clinic herself in order to 

ensure that she made it to the nurses. The traditional healers used by the 

black communities however often prescribe remedies to patients, certain of 

which made psychiatric illnesses much worse. In addition, the problems of a 

paranoid and delusional patient were generally exacerbated by traditional 

healers who told them that their illness was the result of a spell cast upon 

them. 

Churches 

Within the district, certain church ministers pose an influential obstacle to the 

service. The psychiatric nurses report that many patients will first go to a 

church minister before accessing official health services. In such situations, 

some of the ministers have counselled patients that their distress arises from a 

lack of faith and have advocated a return to God as the only remedy. To this 

end, patients are frequently encouraged to stop taking their medication and 

many will do so. 

16


Chapter 3 

Key Issues and Problems 

3.1 Prescribing 

The situation with regard to prescribing of psychiatric medication appears to be 

fairly confused. 

The two psychiatric nurses administer vast quantities of psychiatric medication 

on a daily basis. After initial interview and diagnosis, it is they who make 

decisions about what medications should be used and commence treatment. 

Their prescriptions are then posted off to Kimberley for approval. These 

prescriptions, however, are for a maximum of six months. This represents a 

change in practice, insofar as until recently, they were only allowed to prescribe 

(without a doctor’s involvement) for a maximum of three months. This however 

was in the period when the psychiatrist visited the region on a quarterly basis. 

When the psychiatrist’s visits were reduced to a six monthly pattern, the nurses 

were told that they may prescribe for up to six months, i.e. until the next 

psychiatrist’s visit. These directions came from the Laura Jantjies, then Chief 

Professional Nurse at West End and now the manager of the provincial mental 

health programme. 

Private doctors also prescribe psychiatric drugs to patients, before or during 

their care through the state psychiatric service. Additionally, private doctors 

play a role in the certification of patients when necessary. 

It is not clear why, if patients can be prescribed psychiatric medication by 

private family practitioners without the supervision of a psychiatrist, it is 

necessary for a psychiatrist (rather than any of the local doctors) to oversee the 

nurses’ prescribing practice once a year. Due to the large numbers of patients 

involved, consultations with Mr Piotrowski can generally only be five, 

occasionally ten minutes long. This appears to be an inefficient usage of skills 

and expertise. 

There is a further issue around the capacity for nurse prescribing of psychiatric 

medications. Many of the PHC nurses who participated in the focus group had 

completed a psychiatric placement as part of their basic training. However, 

because they are not currently in a specialist psychiatric post, they are unable 

to care in any way for patients who have a psychiatric disorder. Amongst the 

group of PHC nurses, there was considerable anger that their skills were 

unused and their training wasted – a feeling shared by PHC nurses and nursing 

staff from the community hospitals. 

The nurses stated that they find it extremely frustrating to be unable to 

diagnose or prescribe when the illness is psychiatric, despite the fact that they 

could manage the psychiatrically ill patient just as well as they could manage all 

other patients. Particularly in emergency situations, with violent or suicidal 

patients, nurses trained in psychiatry find it farcical, if not tragic, that they are 

17


unable to prescribe even the most common transquillisers. Instead they must 

wait for the psychiatric nurse practitioners or a local GP to arrive at the scene, 

which may easily be 24 hours later. 

It is worth noting that PHC clinics do not store Schedule 5 psychiatric drugs 

within their drugs store, which eliminates many drugs such as tranquillisers 

which may be needed for emergency patients in an acute phase of illness. 

3.2 Relations with other district healthcare providers 

One consequence of the fragmentation of services which characterised health 

services in the past was poor communication and working relationships 

between different health care providers. In the case of psychiatric services, 

however, this problem was exacerbated by the traditional stigmatisation and 

segregation of psychiatric services and patients. This remains an ongoing 

problem for the psychiatric service which affects their dealings with other 

healthcare providers such as the local hospital, the GPs and PHC staff. Such 

poor inter-relationships constitute a poor basis on which to attempt integration 

of psychiatric services into the wider district health system. The nature of the 

working relationships within Lower Orange are examined below. 

Referrals from and to PHC 

The psychiatric nurses frequently refer patients to PHC clinics, as described 

above. They tell all their patients early on in treatment that whenever they 

attend a PHC clinic, they should take with them any medications which they are 

taking at home in order to avoid confusion. This system appears to fall down 

with patients who receive their medication in injectable form. 

Patients are often referred to the psychiatric clinic without a letter, but are 

simply told by PHC nurses where the clinic is and are told to present themselves 

to the nurses. Some of the letters which accompany patients from PHC clinics 

give little or no history and are inappropriately phrased. 

Epileptics 

Despite the fact that epilepsy is not a mental illness, studies of mental health 

services in other areas of the country have found that the psychiatric service is 

expected to provide long-term care for epileptic patients. In the Lower Orange 

region, epileptics were under the care of the psychiatric service until 1988, 

when they were gradually transferred into the care of the district surgeon; 

these days, the aim of the psychiatric service is to transfer patients with 

epilepsy into the care of their local PHC team as soon as their epilepsy and 

subsequent hallucinoses are controlled. This generally means that epileptics 

remain under the care of the psychiatric service only for two or three months. 

The only exceptions to this rule are three epileptic patients whose care is 

unusually complex as a cocktail of four or five different drugs are necessary to 

control their epilepsy. 

18


The psychiatric nurses feel that there is however an inadequate level of 

understanding of the nature of epilepsy and the management of the epileptic 

patient amongst PHC staff; in each individual case, they have given detailed 

instructions for the care of the patient to the local PHC staff concerned. 

Despite such efforts to educate PHC staff, however, new patients displaying the 

same set of symptoms are still referred to the psychiatric service. 

Inappropriate referrals 

The psychiatric nurses perceive that there is a lack of willingness amongst PHC 

staff to care for patients with mental health problems, and they feel too that 

PHC staff frequently attempt to “pass the buck”, i.e. to refer patients who 

display any strange behaviour whether or not they are psychiatrically ill. In 

many such cases, patients are actually suffering from an organic illness which is 

causing their confusion or delirium. 

The following two cases studies are based on patients who have been referred 

to the psychiatric clinic in recent years and are illustrative of the many similar 

stories which the nurses have to tell: 

Case Study 

A man arrived at the psychiatric clinic with a referral letter from the PHC clinic 

where he had presented the previous day. The referral letter said that the man 

was very disturbed and aggressive and he needed to see a psychiatrist. As part 

of their initial interview, the psychiatric nurses measured the patient’s blood 

pressure, which they discovered to be 210 over 100. On discovering such 

severe hyper-tension, the psychiatric nurses referred him directly to Gordonia 

casualty. They did not open a file for him as there was nothing to suggest that 

he was mentally ill. 

Case Study 

A young woman of around eighteen years of age was referred to the psychiatric 

clinic. Her family were complaining that she was displaying very strange 

behaviours which had started very suddenly and unpredictably. The family had 

been initially to their local PHC clinic, who had seen the girl and then referred 

them to the psychiatric clinic. The psychiatric nurses took a full medical history 

and established that the girl displayed all the classic symptoms of diabetes. 

When pressed, the girl also admitted that she often woke up with bruises to her 

head and legs of which she knew no cause. The nurses referred the family 

back to the PHC clinic, asking for investigations into a potential diagnosis of 

diabetes and epileptic fits to be done. This diagnosis was confirmed and the 

girl was not added to the register of psychiatric patients. 

The feeling of those involved with provision of the psychiatric service is that 

patients displaying any strange behaviours at all are immediately and often 

19


inappropriately referred to their service without the basic necessary 

investigations being carried out first to eliminate any alternative diagnoses. This 

stems partly from the PHC staff being overwhelmed with patients, but also from 

an approach which separates mental health problems into an altogether 

separate category and denies patients with any behavioural problems the right 

to initial treatment equal to that received by all other patients. 

Moreover, the nurses perceive that once a patient is established to have 

psychiatric illness and is under the care of the psychiatric service, their care in 

all regards becomes the concern only of that clinic and not of the 

comprehensive medical service. In Sister Muller’s words, “Once she becomes 

my patient, she becomes the psychiatric clinic’s problem and not everyone 

else’s”. 

This suggestion that PHC nurses do not want to take any 

responsibility for psychiatric patients is not borne out by discussions 

with them. On the contrary, many PHC nurses expressed a strong 

desire to utilise their psychiatric training and take on the care of 

psychiatric patients. What prevents them from doing so is the lack of 

integration of services and the restrictive legislative framework which 

prevents PHC nurses from prescribing psychiatric medications. 

It was however readily acknowledged by PHC nurses that many of them and 

their colleagues had not completed any psychiatric training and that there may 

therefore be difficulties at PHC level in identifying psychiatric problems and in 

distinguishing them from strange behaviours caused by other factors. 

The discussions around this issue and the very different perceptions of the 

problem by different parties strongly suggests a need for training and for 

bringing all the stakeholders within mental health services together so that 

some understanding of others’ perspectives can be developed. 

Private doctors 

The nurses report some difficulties in working relations between themselves 

and some (but not all) of the local family practitioners. They feel that some 

doctors have little respect for their expertise and resent the fact that the nurses 

are able to prescribe. 

The nurses perceive in the doctors a lack of understanding of developments in 

mental health over the years since they trained and a (potentially consequent) 

tendency to mis-diagnose. They report that almost all patients who have seen 

a doctor will be diagnosed as schizophrenic, whereas schizophrenics make up 

only a small percentage of their own diagnoses of the same patients. 

Moreover, they report too that almost all patients will have been prescribed a 

28 day dose of Moducate (a Fluphenazine dekanate drug used in the treatment 

of schizophrenia) by the private doctors, despite the fact that this is in fact 

contra-indicated for patients with organic disorders. Most commonly, a patient 

with alcohol-induced delirium will be mistakenly diagnosed and treated as 

psychotic. Such an error is unnecessarily damaging and moreover will delay 

20


the onset of more appropriate treatment as the nurses cannot prescribe 

another psychiatric drug for 28 days until the first drug is out of the body. 

Finally, the psychiatric nurses believe that the local GPs do much to maintain 

the stigmatisation of mental illness. They cite one particular letter from an 

Upington family practitioner which simply say “Go see the head doctor”. 

3.3 Lack of District Inpatient Facilities 

The lack of a inpatient facility within the district is a prime weakness of the 

service, curtailing the options for treatment. In particular, there is no capacity 

for short-term admissions aimed at observation and stabilisation. Because of 

the distance of Kimberley, admission is a last resort. The distance of the 

hospital also makes it inappropriate for the gradual re-integration of patients 

into their communities, making family visits impossible and thus cutting the 

patient off from their social networks and support. 

In addition, there are many practical and logistical problems with the operation 

of the referral system to West End from Lower Orange. One arises with regard 

to homeless patients: the West End Hospital will not accept a patient unless 

he/she has a return address. This means that “drifters”, with no fixed address 

cannot be referred to Kimberley however severe their condition. 

Transport 

Transport of patients to the West End Hospital is a difficult issue and a priority 

for attention. There is a long-running dispute between the police and the 

ambulance service regarding whose responsibility it is to transport psychiatric 

patients. The only “ambulance service” to Kimberley is a communal minibustaxi 

which transports all patients requiring a referral once a week. For this 

service to transport the certified patients presents problems both of timing and 

of suitability/safety. The health department therefore maintains that it is the 

responsibility of the police service to transport the patients. 

However, at present certified patients travel to West End in the communal minibus 

despite the fact that this makes the journey just once a week. In the 

intervening period, patients are usually held by the police. If there is any 

possibility of doing so, the psychiatric nurses will generally postpone having a 

patient certified until the day before the ambulance is due, so as to minimise 

the length of time that a patient must be held in a police cell or sedated in 

hospital. 

Obviously, placing highly suicidal or violent patients in an ambulance with other 

patients for a gruelling 4-5 hour journey is far from ideal; in this situation, 

psychiatric patients on their way to West End are heavily sedated by the 

psychiatric nurses before the journey. 

21

3.4 The lack of information 


One major factor which hampers the service is the lack of available data. This 

means that there is little ability to monitor and evaluate the performance of the 

service. It also means that there is no data about the profile of the patient 

population, or prevalence rates within the district which would provide a basis 

for targeting and planning of the service. 

For the purposes of this study, analysis of each of the 514 patient records held 

within the Upington clinic was carried out in order to develop a picture of the 

nature of the mental health problems of patients presenting to the clinic. The 

breakdown of the diagnoses of the patients, using the categories and 

terminology within use at the clinic, is as follows: 

Number 

of males 

Number 

of 

% total 

male 

% total 

female 

Total 

number 

% Total 

patients 

Females 

of 

patients 

Affective 33 103 12% 43% 136 27% 

disorders 

Schizophrenia 112 77 41% 32% 189 37% 

Organic 85 39 31% 16% 124 24% 

Disorders 

Personality 3 2 1% 1% 5 1% 

Disorders 

Alcohol/ 21 7 8% 3% 28 5% 

dagga abuserelated 

disorders 

Mental 19 13 7% 5% 32 6% 

Retardation 

Total 273 241 100% 100% 514 100% 

It would be valuable to compare these figures with any national figures for the 

incidence of mental illness within the population. Such a comparison could be 

used as the basis for local service planning and prioritisation. 

In two particular areas the lack of information is an acute problem. Firstly, 

there is an urgent need for data which would indicate the extent of substancemisuse 

within the district. Secondly, the rate of suicide is not known, although 

it is commonly taken as a prime marker for the incidence of mental ill-health 

and also as a key indicator of the performance of a mental health service. 

Substance-related illnesses 

Given that the local agricultural economy is based on production of alcohol, one 

might expect the incidence of alcohol-related illness to be high. Indeed, the 

psychiatric nurse practitioners report that the area has a high incidence of 

senile dementia in the under 50s which clearly arises as a consequence of 

alcohol abuse. This claim is not substantiated by the figures above, but this 

22


discrepancy may arise due to patients being categorised within a broader 

definition of their illness. All nurses involved in the study reported that they see 

many patients who suffer from the long-term effects of alcohol abuse, such as 

chronic hallucinations, even after they have stopped drinking alcohol. In 

addition, during the period of withdrawal from alcohol, epileptic-type fits and 

mental health problems are common. 

Dagga-related problems are also widely mentioned as a cause for concern and 

some shock was expressed at the young age at which children evidently begin 

using it (as young as twelve years old). 

Research is urgently needed to establish the extent of substance abuse so as to 

allow for services to be planned and targeted appropriately. This is in line with 

national policy which has directed that substance-abuse services should be a 

national priority. 

Suicide 

The psychiatric nurses report that they are called into Gordonia Hospital on 

average two or three times a week to attend to attempted suicide patients, who 

are normally aged between sixteen and thirty. A significant number of patients 

will never end up in Gordonia as they will successfully take their lives. 

Significantly, most of the attempted suicide patients were not known to the 

service beforehand. However, both Gordonia casualty staff and the psychiatric 

staff concur that the majority of the patients who attempt suicide have no 

psychiatric illness and are triggered solely by specific events rather than 

delusion or depression. 

In addition, the PHC nurses participating in the focus group identified suicide, 

particularly teenage suicide, as one of the major mental health issues that they 

regularly faced. They too suggested that the suicide figures do not correlate 

with the actual prevalence of psychiatric illness. However, a broad concept of 

mental health must surely attempt to tackle all attempted suicides and to the 

causes of such attempts, particularly unplanned pregnancy. 

Neither the psychiatric nurses nor the DMT are aware of the actual suicide rate 

for the region; this may perhaps be established through the Provincial 

Department of Health or the Home Affairs Department, but it may be that the 

information is not collated as such by any authority. If the true rate can be 

extrapolated from the figures at Gordonia Hospital, this would be a worryingly 

high level. Consequently, the need to establish the suicide rate is an urgent 

one. 

23


Chapter 4 

Integration of Mental Health into PHC 

4.1 National and Local Context 

The 1995 White Paper, Transformation of the Health System, outlined the way 

forward for the development of mental health services in South Africa. The two 

following principles of development are set out: 

(1) A comprehensive and community-based mental health service 

(including substance abuse prevention and management) 

should be planned and co-ordinated at the national, provincial, 

district and community levels and integrated with other health 

services. 

(2) Human resource development for mental health services should 

ensure that personnel at various levels are adequately trained 

to provide comprehensive and integrated mental health care 

based on primary health care principles. 

The implementation of these principles within the Lower Orange/Northern Cape 

scenario over the coming months presents a great challenge. The psychiatric 

service at present lacks the comprehensive approach a primary health care 

philosophy suggests; is overwhelmingly curative in approach and is 

fundamentally distinct in its delivery from other services rendered at community 

level. 

On the other hand, Lower Orange is lucky to possess a sound and wellestablished 

service, and staff in whom those patients on the psychiatric register 

clearly have a great deal of confidence. The expertise and experience of Sister 

Muller and Sister Diergaart will be of immense value throughout the training 

and preparation which will take place to facilitate successful integration of the 

service. 

In addition, and no less crucially, this study found that health professionals 

across PHC services within Lower Orange are extremely positive about the 

concept of integrating mental health services into PHC and fully support the 

thinking behind the move. It is on this strength of feeling that training and 

preparation must build in the next few months. Developing the human 

resource capacity to deliver a district/community level curative and 

rehabilitative service will be no small task; issues both of clinical skills and 

knowledge, and also of time, will need to be addressed. 

Finally, it is positive to note that a wealth of ideas exists amongst both 

psychiatric and PHC staff regarding the priorities for preventative services, 

especially with regard to substance abuse prevention and management. There 

is clear agreement at grassroots level with the national prioritisation of 

substance misuse services. The transfer of the care of stable psychiatric 

24


patients into PHC presents the district with a rare opportunity to transfer staff 

from curative to preventative work. A transfer of this sort would be very much 

in line with national policy and yet also fulfil pressing local needs. 

However, preparation for integration must acknowledge that there are very 

strong fears about what change might mean for individuals and their jobs. The 

psychiatric nurses are extremely concerned that they will be transferred into 

generalist PHC roles for which they are unprepared and which would not make 

use of the expertise they have developed over many years. This fear is based 

on the experiences of psychiatric nurses in areas such as the Western Cape 

where many psychiatric nurses have been forced into undertaking increasing 

amounts of generalist work. 

For their part, the PHC nurses fear that they will be expected to take on a role 

for which they are unprepared and about which they have little confidence. 

Furthermore, they are concerned about the additional work which change will 

bring and their physical capacity to cope with an additional and complex 

workload within the clinics. Training and preparation for change must directly 

address these fears. 

Finally, embarking on the process of change should not happen in a vacuum. 

Integration of psychiatric services into PHC has already been attempted in 

various provinces and districts of South Africa, with varying degrees of success 

and these lessons should be taken on board by the Lower Orange DMT. 

Analysing developments in KwaZulu-Natal, Peterson 4 suggests that there is a 

danger that integration into a generalist curative context results in the loss of 

the holistic patient approach and the special therapeutic relationship that 

develops between psychiatric nurse and patient. She also makes three practical 

recommendations for district integration: firstly, that specialist psychiatric 

nurses in their new role work to an agreed, written and visible job description; 

secondly, that psychotropic drugs become part of the primary care essential 

drug list; and thirdly, that resources transferred from provincial to district 

budgets to facilitate integration initially be ringfenced within district budgets so 

as to ensure that mental health retains its current levels of funding. 

Working within the Western Cape, Muller 5 makes similar observations about the 

effect of integration upon the funding of psychiatric services. She warns that 

the subordinate status of mental health leads to its low prioritisation by district 

management teams and that consequently, integration into the district often 

implies a loss of resources. This applies not only to financial resources, but also 

to human resources: she observes that becoming a part of the primary health 

care team too often means the loss of time dedicated to mental health work 

specifically. 

4 Peterson, I. (1998), Organisational Barriers to Comprehensive Integrated Primary Mental Health Care, 

Department of Psychology, University of Durban-Westville, work in progress 

5 Muller L. et al (1998), Mental Health Integration at the District Level in the Western Cape, Department 

of Psychiatry, University of the Western Cape, work in progress 

25


The lessons that can be drawn out of the experiences of both KwaZulu-Natal 

and the Western Cape provinces are worth considering as the planning process 

gets underway in Lower Orange. 

4.2 First Steps 

The immediate need is for a clear vision of what “integration” actually means to 

be developed and shared by all involved. What is abundantly clear from 

discussions with key roleplayers is that no notion of how services will in future 

be delivered is yet shared. On the contrary, it seems that there are significantly 

different notions of how far the service will be reconfigured. This reflects 

Muller’s finding in the Western Cape that even after the process of change has 

been underway for some years, there is no one agreed notion of what “an 

integrated service” will look like. 6 In order to avoid such confusion in Lower 

Orange, the vision must be established before any change process actually 

begins. 

The basic question concerns how far curative services will be transferred into 

the community. Amongst key roleplayers, two major future visions of the 

future appear to exist: 

(A) 

(B) 

Management of all psychiatric patients is transferred to PHC clinics which 

would then have direct referral rights to the West End hospital if a 

specialist psychiatric service was needed 

Management of all stable patients is transferred to PHC level; a more 

specialist psychiatric service is maintained to take referrals from PHC 

level of new or relapsed patients and to supervise PHC clinic staff. 

Which of these options is chosen as the future vision of services can only be the 

decision of the district management team together with relevant staff. It 

should however be a decision made as soon as possible and in consultation 

with ideally with representatives of the wider community. 

Local developments should however reflect the nationally prescribed framework 

for the development of local mental health services. The national guidance 

argues that districts should maintain their own specialist psychiatric 

services and that PHC staff cannot be expected to manage new or 

relapsed patients on their own. For this reason, the recommendation 

of this paper is that option B is adopted as the future model of 

services. Within Lower Orange, this would constitute a similar role to 

that now taken by the District TB co-ordinator. 

In order to help Lower Orange decide how best to adapt their own services, the 

specifics of the nationally prescribed framework as laid out in the White Paper 

are outlined below. 

6 ibid. 

26


4.3 The role of the district 

The White Paper lays out the direct responsibilities of the district in provision of 

mental health services as follows: 

“At district level, the health authorities will ensure the comprehensive 

integration of mental health services with other services. Planning of mental 

health services should be undertaken, with the active participation of various 

stakeholders, especially the communities. 

i. Providing mental health and substance abuse prevention, promotion and 

rehabilitative services, giving special attention to the planning, 

implementation and co-ordination of community-based rehabilitation 

ii. Planning and implementing inpatient and day-patient care for the 

mentally-ill and substance abusers, establishing a 24 hour consultation 

service for mentally ill patients and victims of substance abuse 

iii. Provide training for health facility staff 

iv. Undertake mental health education programmes in communities 

v. Establish and maintain mental health committees and maintain 

collaboration with other sectors, private practitioners, traditional healers 

and NGOs 

vi. Provide emergency and crisis intervention services 

vii. Collect data, initiate and contract out research in accordance with local 

needs, with the support of relevant institutions 

viii. Develop appropriate indicators for monitoring and evaluation 

It is important that data collection, analysis and resultant action be performed 

at each level and appropriate feedback given , especially to the communities”. 

What needs to be done within Lower Orange to implement this plan? 

Clearly, there is a huge gap between the service which Lower Orange currently 

offers and the vision of district service suggested in this list. It would be 

unrealistic to aim to develop a service along these lines in anything except the 

very long term, given the external constraints at national and provincial level. 

However, the list does provide a framework around which to plan the 

decentralisation of Lower Orange’s services. Essentially, the list above 

describes five main functions. The development of each function is discussed in 

more detail below: 

1. Specialist service provision 

2. Planning of services 

3. Training of staff 

4. Prevention and promotion work 

5. Intersectoral liaison 

27

1. Specialist Services provision 


Lower Orange lacks many of the more complex services which the White Paper 

delineates as district level services. However, the transfer of stable patients 

should free up time of specialist staff such that they are able to develop this 

new role. 

Of the specialist services outlined, the most pressing local need in the eyes of 

healthcare staff is for alternative therapies to be available, particularly 

counselling and a state psychologist. The White Paper recommends that the 

skills of all specialist mental health staff be upgraded to include counselling 

skills and the relevant staff appear to be keen to undertake such training. 

The other option in terms of developing specialised services is to take up the 

issue of the usage of Mr Piotrowski’s time. If one of the doctors from Gordonia, 

or one of the GPs, could fulfil the role of giving yearly approval to the five 

hundred prescriptions, the six days a year that Mr Piotrowski spends in 

Upington could perhaps be used to deliver more specialist services such as 

psychotherapy, depending of course on Mr Piotrowski’s specialisms. 

Alternatively, the district could negotiate with the Provincial office and replace a 

proportion of Mr Piotrowski’s visits with visits by one of the Kimberley 

psychologists. These will not be simple discussions but should nevertheless 

taken up with the provincial office by the DMT. 

In the longer term, the DMT should aim to develop facilities and protocols for 

the management of even acutely ill psychiatric inpatients within the district, 

thus avoiding the need for referral to Provincial level of what should be a 

district-level service. This facility would enhance the capacity of the specialist 

psychiatric staff to deliver a high quality of care within district boundaries. 

Psychiatry ought to move towards the models of care evident within other 

specialties, such as paediatrics, which rely upon local generalist medical staff 

rather than consultants. 

Finally, it is worth noting that some specialist services, specifically mental 

disability and psychogeriatric services, are delineated as provincially rendered 

services. Lower Orange should therefore lobby the provincial office for the 

creation of services in these areas. 

2. Planning and information 

Plans have already been laid at DMT level for taking over the operational 

management of the psychiatric service. However, the DMT’s responsibilities in 

taking on mental health must develop beyond pure operational management 

into a more strategic role: the monitoring of the service’s success rates and 

analysing the quality of service delivered must be carefully undertaken, 

especially in the period following transfer into the community. 

It is crucial that decisions about what indicators might be appropriate and 

valuable within the local context are reached collectively by local staff, including 

the DMT. For example, pertinent data might include the district suicide rate 

28


(both of the community as a whole and of known psychiatric patients). 

Alternatively, it might simply be a comparison of national figures for prevalence 

rates of various mental illnesses against local figures with regard to targeting of 

prevention services. 

The White Paper recommends that DMTs should be trained to improve their 

capacity to supervise, monitor and evaluate services and programmes within 

their district. Some external training in developing the capacity and knowledge 

of the Lower Orange DMT within this field may well be helpful as it is a new 

area for most staff. 

3. Training of staff 

Training of DMT level staff may be deemed necessary as described above. 

However, the main training agenda must of necessity primarily concern PHC 

staff. The White Paper places great emphasis upon the need for comprehensive 

training of PHC staff before integration of mental health services can occur. 

Specifically, it suggests that: 

“Staff at the lower levels, i.e. clinics and community health centres, 

should be trained to do basic screening and counselling and to identify 

and refer patients for further assessment and management.” 

Of course, many of the PHC Sisters, particularly those more recently trained, 

have completed a psychiatric element to their training and many of these 

maintain a high level of knowledge and skill within this area. Others however 

feel that their diagnostic skills and knowledge base have been reduced due to 

lack of use. Yet another group of PHC nurses have never received any training 

in mental health. In order to ensure that all staff share a common knowledge 

base which is up to date with recent developments, a common training 

programme should be delivered to all PHC staff. 

One danger which seems to be evident within the district is to assume that a 

PHC clinic will cope with psychiatric patients if some, or at least one of its 

nursing staff is trained in psychiatry; of the PHC clinics within the district, only 

Keimoes and one of the four Upington clinics have no staff trained in psychiatric 

care. The suggestion seems to be that only staff whose basic training included 

a psychiatric component should undertake care of the psychiatric patient. This 

approach is worrying for two reasons: 

• it fails to de-segregate psychiatric patients from all other patients and 

facilitate the identification of mental health problems in all patients who pass 

through the clinic 

• it is not a workable solution in that there will be no staff to see a psychiatric 

patient whenever the appropriate member(s) of staff are on leave or off 

duty 

29


It is therefore recommended that all staff undergo training and that emphasis 

be put upon complete integration of mental health care within the clinic 

environment. On the basis of this study’s findings and of the many suggestions 

made by healthcare staff who participated in this study, a training programme 

containing the following components is suggested: 

SUGGESTED TRAINING PROGRAMME FOR PHC NURSES 

1. The concept of mental health (and its distinction from a narrow notion of 

psychiatric illness). 

2. Acknowledging and overcoming fears about mentally ill patients 

3. How to recognise the earliest signs and symptoms of mental ill health 

4. Basic listening skills – how to ask the right questions 

5. Psychiatric medications – what, when, how 

6. How to spot signs of relapse and the need for a change of medications 

and/or referral 

7. Referral protocols 

8. The role of the family in care for the patient and in ensuring compliance 

9. Coping with violence and aggression 

10. The need to follow up defaulting patients 

During the study, acute concern was expressed by PHC nurses that the training 

is provided before they take on responsibility for psychiatric patients. Some 

cited the transfer of curative services into their remit as an example of being 

given the workload and only afterwards being given the training. Clearly all 

efforts should be made to ensure that this situation does not occur again. 

4. Prevention and promotion work 

In this area, the suggestions made in the White Paper concur totally with the 

suggestions made at local level. All role players in healthcare provision agree 

that there is an urgent need for the systematic provision of health education 

and promotion activities aimed at preventing mental health problems. 

Schools work 

30


The most immediate need was universally felt to be an education programme in 

schools. The issues which were most commonly identified as those which 

needed to be addressed through such a programme were: 

• Substance abuse (both alcohol and dagga) 

• Safer sex/AIDS/teenage pregnancy/STDs 

• Physical and sexual abuse 

• Stress 

• Teenage suicide 

The psychiatric nurses were particularly keen to train groups of teachers in the 

identification of mental health problems amongst their pupils as a means to 

reducing the number of teenage suicides and attempted suicides. 

Community Education 

It was also widely felt that the community as a whole has very little 

understanding of mental health. Participants in the focus group of PHC staff 

argued that their role in referring patients to the psychiatric service was 

hampered by the common perception that people with psychiatric illness were 

uniformly and simply “mad”. Many PHC nurses reported that families and the 

community had little vocabulary available to them with which to deal with 

mental health problems around them; the repeated sole word in use was 

“mad”. It was felt that a programme or campaign of adult education was 

necessary to educate the local communities about the causes and nature of 

mental ill-health. Many PHC nurses argued strongly for education which gave 

people an understanding the biological bases of mental illness and explained 

the most common forms of mental illness such as depression. It may be hoped 

that such a programme may also develop the communities’ willingness to be 

active participants in caring for the mentally ill and in preventing mental illhealth. 

5. Intersectoral liaison 

The White Paper suggests that liaison should occur at district level with NGOs, 

private practitioners and traditional healers. 

Within Lower Orange, however, the most urgent priorities for development of 

relationships outside the Department of Health and Welfare are with transport 

services, the police and the Department of Education. These relationships 

should be built up at district level to support collaborative working at 

community level, particularly with regard to education, where the authority of a 

“high level” agreement is needed in order to encourage schools to accept their 

role in health education. In addition it is worth noting that a closer working 

relationship between the two sections of the Department of Health and Welfare 

would in itself be extremely valuable. 

Further intersectoral liaison needs are outlined in the next chapter. 

4.4 The role of the psychiatric nurse practitioner 

31


If the DMT goes ahead with implementing any degree of integration of curative 

mental health services to PHC level, a question mark is obviously created over 

the roles of the two members of staff currently providing that service. 

It is recommended that this question mark is used as an opportunity to develop 

the scope for the of the role of the psychiatric nurse practitioners. Drawing 

solely on the national framework outlined above, their future roles could include 

some or all of the following: 

• Training and supervision of PHC nurses in identification and referral 

• management and stabilisation of new or relapsed patients 

• education within the community, especially within schools 

• provision of an emergency or crisis intervention service 

• provision of alternative therapies such as counselling (after training 

as appropriate) 

• provide a limited “day hospital service” for observation and therapy 

with patients during the day 

• manage psychiatric inpatients admitted as short term patients (48/72 

hours) to Gordonia Hospital for stabilisation and observation 

Which of these responsibilities are taken on by the nurses concerned is a 

matter for negotiation between the DMT and the two nurses over the coming 

months. 

4.5 Management and accountability arrangements 

The accountability structures currently in place are fairly complex: 

• The salaries of the two psychiatric nurses have recently been transferred 

such that they are now paid by the district 

• The district PHC Chief Professional Nurse provides direct management 

support, in the form of authorising leave etc. 

• The personnel files for the two staff still remain in West End Hospital, 

Kimberley 

• Clinical accountability remains with West End Hospital 

• Operational management of the service is the responsibility of the manager 

of the provincial mental health programme based in Kimberley. 

The psychiatric nurses feel very strongly that their clinical accountability must 

be to the West End psychiatrist, Mr Piotrowski. This is a long-standing 

arrangement which reflects the fact that the two Upington posts were until 

recently employed by the Provincial Department of Health. An good working 

relationship is still enjoyed with West End which certainly helps the service run 

smoothly. Furthermore, the psychiatric nurses clearly feel that on clinical 

issues, the only appropriate person to whom they should be accountable is 

another experienced psychiatric specialist. 

It is not clear whether the DMT forsee that the clinical management of the 

service will also transfer to them from April 1999. If this is indeed deemed to 

be necessary, such that the psychiatric services are fully devolved to the district 

32


level, discussions between the psychiatric nurses, West End and the DMT will 

be necessary. 

33


PROJECT PLAN: INTEGRATION OF MENTAL HEALTH SERVICES (OPTION B MODEL) 

1. Project management and strategy 

Integration of the service will take many moths, if not years, and will involve many people. Such a complex project requires a team to plan 

and monitor its progress and who will take clear charge of the change process. The team should include key roleplayers such as the 

provincial manager of the mental health programme, the DMT’s CPN in charge of PHC, the psychiatric nurses and the district pharmacist. 

The first task of the team is to agree what the aims of integration are and to agree a vision of what the service should look like in three 

years’ time. Secondly, responsibility for each specific stage of this project plan must be allocated amongst the group. 

1. Establish a project team 

2. Establish visions and aims 

3. Agree project plan and a broad implementation timetable and allocate responsibilities for each step 

4. Address question of mental health representation on the DMT 

5. Visit Springbok and De Aar as a fact-finding trip 

6. Choose one pilot site (of three outreach services 7 ) and agree with the PHC staff there a date for integration 

7. Organise meeting with patients and families to explain the changes and meet the PHC staff 

8. Monitor pilot site for three months and learn lessons 

9. Roll out integration to two other clinics 

10. Gradually transfer Upington patients to local clinics 

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 transfer to a new clinic as in Upington 

34


2. Information requirements 

There are many aspects of the integration which cannot be planned or implemented successfully without a complex analysis of information 

beforehand. For example, to identify which psychotropic drugs will need to be stocked by each PHC clinic, the team will require information 

about which patients will be seen in which clinic and what medications they each receive. If integration occurs without this information 

having been gathered, PHC clinics will not have the medications available at the right time for patients, which may have serious 

consequences. Similarly, if clear information is not available regarding which patients will transfer to which clinics, their medical records 

cannot be moved to the appropriate location. Completing all the following stages of information gathering is therefore a pre-requisite of 

beginning the actual transfer of patients. 

1. Devise criteria to distinguish “simple to transfer” patients from “complex” patients 

2. Establish how well known the psychiatric patients are to the PHC nurses 

3. Allocate patients now seen centrally in Upington to local clinics based on their addresses 

4. Agree with psychiatric nurses and PHC clinics exact numbers and identities of patients to be transferred to each clinic (= 1 + 2 + 3) 

5. Based on 4, plan for the transfer of patients’ medical records to the clinics (must occur prior to complete handover of patients) 

6. Gain data from the Province necessary to plan for taking over the drug postal service (quantities, frequency, cost etc.) 

7. Gain data from the Upington psychiatric nurses regarding each patient’s medications and (using information 4. Above), calculate 

therefore what the drug needs of each PHC clinic will be 

8. Calculate therefore what the demands on the Gordonia pharmacy will be for monthly distribution of drugs ( = 5 + 6) 

35


3. Training 

PHC nurses will require both formal “academic” training in psychiatric work and also informal training through supervision as they begin to 

see psychiatric patients. Both these forms of training MUST occur before complete handover of patients can occur, although supervision of 

PHC nurses should continue for some time after integration occurs. It is important that both provincial and local sources of expertise are 

used to deliver the training and the content of the course should be agreed by the entire project team. A suggested agenda for the 

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 

with no prior psychiatric training. However, it is not only nursing staff who require training: the White Paper demands that DMT receive 

some training in the management of a psychiatric service so that they are able to monitor and evaluate its performance, using appropriate 

indicators and understanding the main clinical issues around psychiatric services. 

1. Identify the proportion of PHC nurses with previous psychiatric training and their distribution across the clinics 

2. Agree content of local programme for training of PHC nurses including new referral protocols between PHC and psychiatric nurses for 

new, complex or non-compliant patients, and new job descriptions for psychiatric nurses (see below) 

3. Establish what support and training Province will offer and agree who will deliver the training 

4. Agree timetable for training of nurses: should outlying clinics be prioritised for training first (as they will receive patients first) or should 

there be a mixture of staff from each clinic? 

5. Deliver formal training modules to PHC nurses in groups 

6. Alongside formal training, familiarise PHC nurses with psychiatric work and the patients by sitting in and watching psychiatric clinics led 

by the psychiatric nurses 

7. Increase PHC nurses participation in the clinic sessions such that patients are jointly managed 

8. Gradually move to a point where the PHC nurses manages the patients and the psychiatric nurse takes on a supervision role only 

9. Establish the training needs of the DMT to take on management of the service (ability to monitor indicators, intersectoral issues) 

36


4. Budget Transfer and Financial Management 

Transfer of the costs associated with provision of the service from the provincial level to the district should not be one of the more complex 

matters. However, it is important that integration into PHC does not mean that money previously spent on psychiatric services is now 

filtered into PHC; integration is not designed to produce a cheaper service but to improve the quality of the service. In order to prevent 

this occurring, the first step is to establish a specific cost centre for mental health and to transfer each cost item into that cost centre. This 

will allow for comparison over time of expenditure on mental health. Experience in countries such as the UK ahs shown that transferring 

care into the community is not a cheaper option than maintaining a specialised service and should not be viewed as an opportunity to save 

money. The DMT should commit itself to maintaining over 5 years the proportion of its expenditure which goes towards mental health 

services. 

A potential difficulty with stage 4 of the transfer of budgets may occur if the provincial financial management system is unable to identify 

expenditure on pharmaceuticals sent to the Lower Orange district as a part of the main provincial pharmaceuticals budget. Without this 

information, it will be difficult to ensure that an appropriate amount is transferred over to the district to finance drug costs. The only way 

to establish an appropriate figure in this situation will be to calculate the cost per year based on the drug stock ordering records kept in the 

Upington clinic. This will not however help with identifying the expenditure within the postal system to Lower Orange. 

1. Establish a new ringfenced cost centre for mental health within DMT budget (separate from PHC) 

2. Transfer salaries of two psychiatric nurses from Province 

3. Transfer miscellaneous non-pay expenditure from Province (travel expenses to clinics, stationary, printed appointment cards) 

4. Transfer pharmaceuticals expenditure from Province (cost of supply to the Upington clinic nurses plus the postal service to Lower 

Orange clinics) 

5. Investigate what “share” of inpatient expenditure at West End Hospital is dedicated to Lower Orange and whether there is potential for 

transfer of these monies into the district to fund development of an inpatient facility within the district 

6. Once all above elements have been transferred into the district budget, calculate the expenditure on mental health as a proportion of 

total district expenditure. This figure should not decrease over time. 

37


5. Development of psychiatric nurse post 

The success of an integrated system hinges upon the quality of the referral process and the supervision and support that generalist nursing 

staff can call upon. PHC nurses need the confidence that they will have easy access to specialist advice and can refer a patient whenever 

they are concerned. Integration in Lower Orange offers the district the opportunity to develop the quality and scope of its services 

considerably without spending any extra money, simply by transferring patient loads away from the specialist staff and thereby allowing 

them to spend more time working closely with difficult patients and developing services for specific client groups such as children and 

adolescents or victims of violence. For this system to work well, however, good planning is necessary to establish very clear referral 

protocols and ensure that there is clarity amongst all health care staff as to each others’ roles within the system. The post of the 

psychiatric nurse will change: during the integration period, they will be required to spend much of their time training and supervising. As 

the new model falls into place, the psychiatric nurses will be able to take on many of the previously lacking aspects of the service, such as 

provision of counselling and a child and adolescent service. 

1. Clarify vision of services as above 

2. Identify role of psychiatric nurse within this model in clear written job descriptions: 

a) during transitional period as integration occurs: supervision and training 

b) on completion of transition: ongoing supervision of PHC nurses, management and treatment of new, “complex” and non-compliant 

patients, provision of alternative therapies and preventive/educational work, inter-sectoral liaison with Welfare and Education 

3. Agree clear referral protocols between PHC and psychiatric nurses for new and “complex”, and non-compliant patients (which must then 

be included in PHC nurses’ training as above) 

4. Provide training to the post holders as necessary, e.g “training the trainers” course, counselling skills, child and adolescent mental 

health, health promotion, domestic violence 

38


6. Drugs Management 

Ensuring that a supply of drugs is available at each clinic is essential to successful integration. The process of developing a district 

distribution system is complicated by uncertainty over the timing of the completion of the district’s new pharmacy within Gordonia Hospital 

and the potential development of a second provincial drugs depot within Upington. The other major issue around drugs management 

concerns the dispensing of Schedule 5 drugs from PHC clinics for the first time, which will require specific training for clinic staff. However, 

there should be no need for drugs shortages as it is entirely possible to predict the demands of each clinic using existing data. It is 

therefore vital that this analysis is carried out and that a very detailed distribution system, based upon this information, is established. 

1. Establish a drugs management group to oversee the transfer, to include the regional pharmacist and the provincial lead on drug issues 

2. Identify how the timing of the integration will coincide with the completion of the Gordonia Hospital new pharmacy block; where will the 

district’s supply of psychiatric drugs be kept in the meantime? 

3. Establish the exact monthly demand for drugs at each clinic on the basis of information as above 

4. Draw up a plan for the monthly distribution of psychiatric drugs to each clinic 

5. Work with PHC clinics on the incorporation of psychiatric drugs into clinic drug stores; ensure that rational drug use management is 

applied i.e. establish minimum and maximum ordering levels, use of stock cards 

6. Train PHC nurses in specific storage, prescribing and dispensing issues for Schedule 5 drugs 

39


7. Transfer of Patients 

This is the final stage of the process and should not be undertaken until all other steps above have been completed. Most importantly, 

systems for drug distribution must be firmly in place and training of all PHC staff must have been completed. It should be remembered 

that many psychiatric patients have been attending the same clinic and seeing the same staff within a set routine for many years and that 

such a change may for some be extremely difficult for them to manage. It is important to recognise that patients have developed a 

therapeutic relationship with the psychiatric nurses over many years which will not be easily replicated with a new nurse. Although the 

change process is hard for staff, it should be remembered that those who may really struggle will be the patients. 

1. Identify which patients transfer will transfer to each clinic and “complex patients” who will remain under the care of the psychiatric 

nurses 

2. Inform the patients individually of the change to their treatment routine; for some, the change will be solely of personnel, for others 

they will have to attend a different clinic altogether 

3. Meeting with patients and their families in each of the four towns to explain the change process. 

4. Transfer care gradually, with psychiatric nurses in attendance as well as PHC nurses for the first months’ visits 

40


Chapter 5 

Strategy for future development 

The final chapter consists of an action plan to address the future of the 

psychiatric service as a whole as it develops into a modern mental health 

service. The following recommendations are based on the findings of the 

situation analysis and include actions both for the short-term and for the very 

long-term. Many of them arise from the suggestions and ideas of the health 

workers who participated in the study. However it is recognised that certain 

long-term recommendations to some extent constitute a wish list impossible to 

deliver under present resource constraints (in human resources as well as 

finances). They are included in part to give an idea of service levels in other 

parts of the country and should ideally exist in the Northern Cape as well. 

1. Health Education and Community Involvement 

Problem Statement: 

1. High incidence of mental health problems which relate to dagga use and 

teenage pregnancy and could therefore be prevented 

2. Lack of community understanding of mental health causes stigmatisation of 

patients and a perception of the mentally ill as a threat 

3. Families unable to identify symptoms in early stages of illness, so 

presentation to the service is delayed until illness is acute 

4. No community involvement in planning of the service 

5. No community involvement in peer education programmes or support groups 

Short term recommendations: 

1. Urgently liaison with the Education and Welfare Departments to develop 

jointly a local schools health education strategy to include substance abuse 

and safer sex education 

2. Extend the health promotion component of the psychiatric nurse post 

Medium term recommendations: 

1. Set up a Community Mental Health Forum to include key role players such as 

teachers, local councillors and religious leaders 

2. Establish a community education programme around child physical and 

sexual abuse and a support group for women who have experienced 

domestic violence 

Long-term recommendations: 

1. Meet with church leaders to establish better relations and communication 

2. Meet with traditional healers to discuss referrals and communication 

3. Establish a joint team of community workers between Health and Welfare 

41


2. Information 


1. Time is spent on form filling without benefit or feedback 

2. Data exists but is not analysed or used for planning 

3. There is no way of measuring the success or improvement of the service and 

consequently no targets can be set 

4. No data collated about diagnoses creating difficulties for decisions about mental 

health priorities and targeting of preventative work 


1. Identify any unnecessary collection of data and cease collection 

2. Allocate responsibility for analysis and feedback to one individual within the DMT 

3. Establish baseline information against which future results can be compared e.g. 

• Proportion of population registered as psychiatric patients (per 10,000) 

• Proportion of patients whose illness is substance-related 

Medium term recommendations 

1. Draw up a further list of data which would be useful to the district in planning 

the future direction of mental health services (suggested indicators for 

evaluating mental health services are given in the 1995 White Paper as goals for 

health improvement by 2000) e.g. 

• numbers of children with mental disability not attending school 

• numbers of suicides (and therefore rate per 100,000 population) 

• Areas in which substance abuse is highest 

• Schools not currently running substance abuse education 

• numbers of patients referred to forensic service per year 

2. Set local targets for improvements within stated timeframe e.g. 

• reduction in numbers of attempted suicides 

• reduction in number of patients referred to Kimberley 

Long-term recommendations 

1. Liaise with Welfare Department regarding victims of rape and domestic violence 

known to social workers 

2. Commission research into prevalence rates of mental illness within the district 

42


3. Scope of Services 


1. No state psychologist or counselling facilities other than social workers 

2. Inpatient facilities only exist in Kimberley, which discourages short-term 

admissions due to distance and cost of travel 

3. No support service for patients or families out of hours needing urgent 

intervention to prevent violence or self-harm 

4. Casualty departments ill-prepared to manage or admit acutely ill psychiatric 

patients, therefore patients detained in police cells 

5. No capacity amongst staff to provide therapies other than pharmacalogical 


1. Work with Gordonia Hospital Casualty in improving protocols for admission 

and management of acute patients overnight, using hospital qualified staff 

and psychiatric nurses as “consultants” when necessary 

2. Commence training of psychiatric staff in counselling skills 

3. Commence joint work with Welfare on provision of services for victims of 

rape/assault/sexual abuse/domestic violence to avoid duplication of efforts 


1. Develop an on-call 24 hour rota (budgetary implications) 

2. Liaise with police to ensure optimum conditions and treatment of patients 

and that police staff have some understanding of mental illness 


1. Work with Gordonia hospital to develop an inpatient service based on 

dedicated psychiatric beds under joint care of psychiatrically-qualified 

Gordonia staff and psychiatric nurse practitioners 

2. Introduce a “lay/peer counsellors” scheme as in operation successfully in 

the Western Cape (Mossel Bay/Langeberg district) 

3. Work towards developing specialist child and adolescent services to be run 

by the psychiatric nurses 

4. Liaise with old age homes regarding psychogeriatric patients, training staff 

to ensure that they have a basic understanding of mental illness, especially 

senile dementia 

5. Maintain pressure upon the Provincial department regarding the urgency of 

appointing a community-based psychologist 

43


4. Role Clarification 


1. Role of psychiatrist problematic: skill mix skewed such that most senior and 

skilled member of the team has little opportunity to work closely with 

patients; his major role is approving and signing prescriptions 

2. Little clarity regarding role of Casualty departments in out of hours service 

3. Epileptic patients frequently referred to psychiatric service although most 

should be manageable within PHC clinics 

4. Local family practitioners prescribe psychiatric medications prior to referral 

without consultation with psychiatric service, resulting in inappropriate 

treatment and delay in onset of more appropriate treatment 

5. Some potential for future duplication between Health and Welfare of 

service provision for victims of rape/abuse/assault as each currently plans 

to develop these services as a priority 


1. Bring together local family practitioners, psychiatric nurses and psychiatrist 

to establish agreement regarding treatment protocols prior to referral 

2. Investigate whether the legal framework does necessitate a psychiatrist’s 

review of the prescriptions each year and if possible, alter the system such 

that a doctor from Gordonia hospital fulfils this role 8 ; similarly, investigate 

the restrictions upon nurse prescribing of psychotropics and the 

implications for integration of psychiatric services into PHC 


1. Ensure that “pre-integration training” for PHC staff includes training in 

management of epileptic patients within PHC 

2. Bring the 4 community doctors who will be rotating through the PHC clinics 

as of January into the psychiatric system and potentially transfer annual 

review of prescriptions to them 

3. Liaise with Welfare to produce a synergy in the development of services 

rather than duplication 


1. Draw up clear protocols displaying visually the role of each sector/individual 

within the process 

8 It is likely that the need for a psychiatrist to review the prescriptions once a year is a condition of the 

permit specifically issued to the Northern Cape’s psychiatric nurses under section 38A of the Nursing Act 

which allows them to initiate schedule 5 drugs for up to 5 months. This permit must have been issued 

under the authority of Mr Piotrowski and could equally be altered by him. 

44


5. Drugs and prescribing 


1. Drugs frequently do not arrive in the “postal system” to outlying clinics 

2. PHC clinics’ drugs store does not include psychiatric medications 

3. PHC professional nurses legally unable to dispense schedule 5 drugs 

4. Inefficient use of psychiatrist’s time in signing 200+ prescriptions 

5. Confusion as to potential location of a second provincial drugs depot in 

Upington 

6. The province proposes to decentralise the provincial drugs system to each 

district and make distribution within districts the responsibility of the district 

pharmacist 

7. Budget for psychiatric drugs currently lies with the province 


1. Investigate the legal and Nursing Council restrictions to gain clarity 

regarding the role of the psychiatrist and the PHC nurses 

2. Prepare for the decentralisation to the district: 

a) establish from the province all the relevant facts regarding the postal 

services, e.g. quantities, frequency 

b) Draw up a plan for the distribution of the drugs within the province 

3. Ensure that all staff are aware that the postal service will cease 

4. Begin negotiations with the province for the transfer of the drugs budget 


1. Ensure that PHC staff have adequate training in use and storage of 

psychotropic drugs 

2. Work with the pharmacist at Gordonia Hospital to prepare for the creation 

of the psychiatric drugs store within the hospital pharmacy 


1. Transfer annual review of prescriptions to community or hospital doctors 

45


6. Transport 


1. Many patients travel considerable distances to receive their medications 

2. Inappropriate facilities for transfer of patients to West End Hospital 

3. Police service does not accept responsibility for transferring certified patients to 

Kimberley even if already charged with a criminal offence 


1. Collect data for a six month period to provide baseline information on which to 

base negotiations (numbers of patients, time of day/night etc.) 

2. Liaise with Gordonia Hospital so that the psychiatric service can take advantage 

of emergency unscheduled trips made to Kimberley 


1. Bring together police, transport, and psychiatric nurses in a meeting convened 

by the Regional Manager to agree a protocol for psychiatric patient transport 


1. As the district develops its capacity to manage acutely ill patients, the resulting 

reduction in referrals should make this less of a long-term problem. 

7. Staff and Patient Safety 


1. Inadequate facilities for the disposal of sharps at the Upington clinic 

threatens the safety of both patients and staff 

2. No policy for action following exposure to blood is known to clinic staff 


1. Provide the clinic with adequate sharps disposal facilities 

2. Train the nursing staff not to build up such a stockpile of used sharps 

3. Provide a copy of the district/provincial/Gordonia policy for action post 

exposure to blood to the clinic and agree a specific written policy for them 

46


Bibliography and References 

Bamford L (1997) Action for Health in Kakamas 1997/8, Initiative for Sub- 

District Support, Technical Report 2a, Durban 

Department of Health (1997) White Paper for the Transformation of the Health 

System in South Africa, Government Gazette No.17910, Pretoria 

Flisher, A. et al (1988), Norms and Standards for Psychiatric Care in South 

Africa, Department of Psychiatry, University of Cape Town 

Health Systems Trust (1997) South African Health Review 1997, Chapter 17: 

Mental Health, Durban 

Helser J.E. and Pyzbeck T.R. (1988), The co-occurrence of alcoholism with 

other psychiatric disorders in the general population and its impact upon 

treatment, Journal of Studies on Alcohol, 49, 219-224 

Jones L (1998) Mental Health Care in Mount Frere, Initiative for Sub-District 

Support, Health Systems Trust, Durban 

Muller L. et al (1988) Mental Health Integration at the District Level in the 

Western Cape, Department of Psychiatry, University of the Western Cape, work 

in progress 

Peterson I.(1988) Training for Transformation: Reorientating Primary Health 

Care Nurses for the Provision of Mental Health Care in South Africa, Department 

of Psychology, University of Durban-Westville, unpublished 

Peterson I.(1988) Organisational Barriers to Comprehensive Integrated Primary 

Mental Health Care, Department of Psychology, University of Durban-Westville, 

work in progress 

47

Table 1 


Appendix 1 

Patients under care of psychiatric service by locality 

Patients seen by Psychiatric nurses in Keimoes 

July 1997 – June 1998 

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 

First 

Visit 

Male/ 

Female 

Follow 

-up 

visit 

0 2 0 0 1 1 0 1 1 0 0 0 

0 0 0 2 0 0 0 0 0 1 0 1 0 0 1 0 1 0 0 0 0 0 0 0 

55 59 55 62 61 54 53 54 56 56 66 60 

Home 

Visits 

0 0 0 0 0 0 0 0 0 0 0 0 

Did Not 

Attend 

6 8 16 10 9 15 0 9 7 10 14 3 8 

• No home visits 

• Fairly even number of patients each month and a lower default rate 

proportional to the total number of patients than Upington 

9 There are no defaulters in January as a new register is started 

48


Table 2 

Patients seen by Psychiatric nurses in Upington 

July 1997 – June 1998 

July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 

First 

Visit 

Male 

/Female 

5 7 8 3 12 6 8 8 13 6 14 9 

2 3 4 3 5 3 2 1 4 8 5 1 7 1 2 5 5 8 4 2 5 9 4 5 

Follow 

-up 

visit 

448 479 481 652 

* 

438 452 432 430 515 598 

* 

439 532 

Home 

Visits 

60 63 72 84 84 42 63 73 97 73 74 108 

Did Not 

Attend 

91 88 89 83 114 147 0 10 47 53 67 96 80 

* The numbers of patients attending the clinic are higher in October and April as these are the 

months in which the provincial psychiatrist visits Upington. Many patients cannot afford to 

attend the clinic frequently and so will see the nurses as well as the psychiatrist during this 

visit. 

Comments 

• Very high number of defaulters, especially around November/December when seasonal 

work availability in vineyards outside the region is highest 

• Home visits include patients in old age homes and in prison; yet breaking down the home 

visits by age demonstrates that only a small percentage are to patients over 65; rather, the 

41-64 age group make up a higher proportion of home visits than of clinic visits. This is in 

part due to the fact that one of the so-called old age homes, ND Swartz, also doubles as a 

centre for people of all ages in need of care, e.g. adults with severe learning disabilities, the 

physically disabled 

• Breakdown by age (not given) reveals the largest category of patients to be between 19 

and 40 years of age; no children under 5 were seen, which suggests that an appropriate 

distinction is being made between children with learning difficulties and adults with mental 

illness. There may however be lack of provision for adolescents: there were only 18 visits 

by patients between 6 and 18 in the entire year, many of which may well be made by the 

same one or two patients. Compared to the national figures for adolescent mental health 

problems, this may suggest gaps in targeting and access. 


49


Table 3 

Patients seen by Psychiatric nurses in Kakamas 

July 1997 – June 1998 

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 

First 

Visit 

Male/ 

Female 

Follow 

-up 

visit 

0 0 1 0 0 1 0 0 0 0 0 1 

0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 

48 48 45 43 40 42 43 47 46 92 11 49 51 

Home 

Visits 

0 1 1 0 0 0 0 0 0 0 0 0 

Did Not 

Attend 

4 3 8 9 14 12 0 12 1 3 2 3 2 

• All the new patients are female – is this significant? 

• Default rate significant only around November/December time, at which 

time numbers of patients seen is at its lowest; clear pattern over the year, 

rising to a peak in winter 

11 There were two visits to Kakamas in April, therefore these figures are the combined total of the two 

visits 


50


Table 4 

Patients seen by Psychiatric nurses in Kenhardt 

July 1997 – June 1998 

July Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 

First 

Visit 

1 3 0 0 1 0 0 1 0 0 0 0 

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 

Female 

Followup 

visit 

38 35 37 35 40 36 36 38 44 39 37 35 

Home 

Visits 

1 1 1 1 1 1 1 1 1 2 1 1 

Did 

Not 

Attend 

2 9 11 11 6 10 0 5 0 5 6 8 

• The one home visit each month is to one individual who is unable to attend 

the clinic due to his delusional state 

• A higher default rate proportionately to the other outreach clinics at 

between 15% and 23% 

51


Appendix 2 

List of clinics represented in the focus group of PHC nurses 

Clinic 

Paballelo Clinic 

Louisvaleweg Clinic 

Pofadder Municipal Clinic 

Grobelershoop Clinic 

SA Defence Forces, Upington Base clinic 

Upington Prison clinic 

The focus group was held on Thursday 8 th October at Upington Fire Station. 

Nursing staff from Kakamas Hospital and Gordonia Hospital also participated in 

the discussion. 

52

Towards an integrated Mental Health Service - Health Systems Trust

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