FACTORS LEADING TO FREQUENT READMISSION TO VALKENBERG HOSPITAL FOR PATIENTS SUFFERING FROM SEVERE MENTAL ILLNESSES HELEN MARY SMITH A mini-thesis submitted in partial fulfilment of the requirements for the degree of Master in Public Health in the School of Public Health, University of the Western Cape. Supervisor: Dr Uta Lehmann Co supervisor: Prof Charles Malcolm May 2005 FACTORS LEADING TO FREQUENT READMISSION TO VALKENBERG HOSPITAL FOR PATIENTS SUFFERING FROM SEVERE MENTAL ILLNESSES Helen Smith KEYWORDS mental health psychiatry severe mental illness deinstitutionalisation relapse psychosis frequent readmission community resources psychosocial rehabilitation care pathways ii ABSTRACT Factors Leading To Factors Leading To Frequent Readmission To Valkenberg Hospital For Patients Suffering From Severe Mental Illnesses H.M. Smith MPH mini-thesis, School of Public Health, University of the Western Cape. This descriptive and analytical mini-thesis aimed to explore systemic health service problems that are related to frequent readmission of persons suffering from severe mental illnesses to Valkenberg Hospital through a comparative study of perspectives of mental health service providers and consumers. Reduction of acute and chronic beds in the Associated Psychiatric Hospitals, Western Cape over the past decade has led to increasing pressure for beds and rapid inpatient turnover, many of these inpatients being ‘revolving door’ patients. Integration of mental health service into general health services, an intrinsic part of the comprehensive primary health care (PHC) approach in South Africa, is supposed to make mental health care more accessible to the public, therefore research into why patients are being frequently readmitted at secondary specialist level is indicated. Qualitative data was collected during September/ October 2004 from six in-depth interviews with service users and two focus groups with service providers. Emergent findings were that the health service platform provides insufficient protection to families against violence associated with mental illness, insufficient mental health promotion and psychosocial rehabilitation, insufficient community support systems with poor c ommunity tenure for mental health care users, care pathways need much improvement and staff resources across the mental health platform are inadequate to address the ‘revolving door’ problem. Resources have not been put in place at PHC level. As result of lack of comprehensive mental health care patients are rapidly revolving through Valkenberg Hospital. This indicates that deinstitutionalisation and devolvement of mental health care cannot work without provision of the necessary infrastructure at community level. It is hoped that this context specific, small-scale study will sensitise service providers, programme managers and inform policy makers to the root causes of frequent readmissions to Valkenberg Hospital with a view to informing further research and improving mental health service provision to the public. May 2005 iii DECLARATION I declare that … is my own work, that it has not been submitted before for any degree or examination in any other university, and that all the sources I have used or quoted have been indicated and acknowledged as complete references. Helen Mary Smith May 2005 Signed: . .. iv ACKNOWLEDGEMENTS My sincere thanks and appreciation in the following special instances: · My supervisor, Dr Uta Lehman and co-supervisor, Prof Charles Malcolm for their intellectual inspiration, challenge, patience, limit setting, support, encouragement and availability · Corinne Carolissen, administrator at School of Public Health for her friendliness, reliability, advice and support · Various senior staff at Valkenberg Hospital for their intellectual inspiration, passion, advice and encouragement, in particular Ms Sue Blyth, Dr Sean Baumann, Mrs Louise Frenkel and Mrs Carol Dean at APH Head Office. · My social work colleagues for inspiring me with their empathy for their clients, and especially to Siviwe Mdunyelwa, Ntathu Mfiki and Nobom Mpongwana for their practical assistance with some of the research and data collection process · Professional psychiatric nursing colleagues from Valkenberg Hospital and from Community Health Centres in the Valkenberg catchment area who took part in the focus groups, for the depth of knowledge and understanding that I received from them and for their generous participation and passionate commitment · Mental health consumers who participated in the research study in depth interviews for their time commitment, as well as what I learned that has enriched me and the respect I have for their courage and determination · Friends, Julia Smuts and Lungelwa Mfazwe for their motivation and encouragement to complete the thesis · My dear and treasured friends for keeping me sane, by knowing when to keep their distance and when to distract me (ditto my cats). · Geoff and Elaine, my parents; Michael, by brother and Penelope, my sister and their families for their loving support and belief in my ability. · Those whom I have not mentioned · Alpha and Omega v CONTENTS Title Page i Abstract ii Declaration iii Acknowledgements iv CHAPTER ONE: INTRODUCTION 1 CHAPTER TWO: LITERATURE REVIEW 6 Trends In Mental Health Policy Internationally And In South Africa 6 The International Trend Towards Deinstitutionalisation 12 Predictors Of Psychiatric Readmission 15 Challenges Of Community Mental Health Care 19 Models Of Community Based Mental Health Care 25 The ‘Revolving Door’ 29 CHAPTER THREE: METHODOLOGY 33 CHAPTER FOUR: RESULTS 49 Theme 1: Violent And High-Risk Behaviour 51 Theme 2: Lack Of Knowledge And Insight 55 Theme 3: Lack Of Social Support Systems 63 Theme 4: Lack Of Adequate Care Pathways 74 vi Theme 5: Lack Of Resources 87 CHAPTER FIVE: DISCUSSION 93 Violence and high-risk behaviour 95 Knowledge, insight and acceptance of mental illness 99 Support systems 105 Care pathways 111 Resources 120 CHAPTER SIX: CONCLUSIONS, 126 RECOMMENDATIONS AND LIMITATIONS REFERENCES 130 APPENDICES 1. Glossary of terms 136 2. Shah (2002) Study of acute psychiatric admissions. 139 P.A.W.C., South Africa. Tables 1.5; 1.6; 1.7 & 1.8. 3. The Mental Health Matrix (Thornicroft And Tansella, 1999) 141 4. Milligan, P.D. & Flisher, A.J. (2002) An Analysis Of 142 Discharge Summary Data Of A Major Psychiatric Hospital 5. Focus group guideline 146 6. In-depth interview guideline 148 7. Data from in-depth interviews and focus groups (see volume 2) vii CHAPTER ONE: INTRODUCTION Incorporation of mental health services into the primary health care approach in South Africa is in a difficult stage of transition. Mental health, along with other health services in the Western Cape, was challenged with the necessity of rationalisation with the 1994 provincial health plan. A Provincial Cabinet Resolution in 1998, the result of public lobbying against Valkenberg Hospital closure, led to restructuring into the Associated Psychiatric Hospitals and reduction of psychiatric beds mostly through de-institutionalisation of long term patients but also closure of acute beds across the four psychiatric hospitals in the Western Cape. Consequently the acute psychiatric units at the four psychiatric hospitals in the Western Cape are cur rently experiencing a crisis with the unremitting influx of psychotic patients from the Metropole and rural areas, and neither staff nor bed capacity to admit more patients. The Healthcare 2010 plan for the Western Cape specifies that human resources be de volved together with patients to primary health care (PHC) level, but staff patient ratios are such that the staff capacity to devolve to PHC level does not exist at Valkenberg or the other Associated Psychiatric Hospitals (APHs), all of which are classified as secondary regional hospitals with specialist functions of psychiatric treatment. Although hospital beds have decreased, the number of acute admissions per annum to the hospital has increased. This is accounted for by the increased flow of population into the Western Cape as well as higher patient turnover. The higher the turnover of patients, the higher is 1 the cost of human resources and therapeutic drugs in respect of diagnosis, treatment, rehabilitation and discharge with sufficient medication. Mental health legislation makes provision for involuntary admission to designated health establishments of persons who are assessed as mentally ill and a danger to themselves or others. Therefore Valkenberg Hospital cannot refuse patients admission or put them on a waiting list in order to retain patients who are inadequately stabilised on treatment. Where further stabilisation of these patients who are discharged to PHC level then fails to take effect, rapid relapse and readmission within weeks of discharge is all too frequently the result. It could be that the ‘revolving door’ syndrome and high chronic morbidity is a cyclical effect of inadequate mental health services due to scarce resources at both hospital and PHC level. Whilst rectifying the problem of scarce resources may at this stage elude us, perhaps there is scope for improving referral pathways in the vulnerable transition period between Valkenberg Hospital and PHC level. It is important to establish how consumers can be treated effectively at community level and what impediments are experienced. National health policy of treatment at PHC level, and our mental health legislation are not contradictory policies. The new Mental Health Care Act 2002 emphasises the least coercive