Report for the Royal College of Psychiatrists

27Jun11

An Out of Programme Experience at Pantang Psychiatric Hospital, Ghana
10 May – 4 August 2010

My report for the Royal College of Psychiatrists website has just been published and is reproduced below. It’s a shortened, reworded version of the Neate Experience in Ghana blog that was posted here in October 2010.

Pantang Psychiatric Hospital's administration building in the frame

Accessing Psychiatry in Ghana

The working conditions are ‘not the best’, treatments are basic and its political priority low; still there’s a lot involved when considering psychiatry in Ghana. This West African country’s culture of collective, family responsibility means that most consultations for those with mental illness are initiated and include their concerned relatives. As superstition and spiritual beliefs are popular and influential, informal healing centres run by traditional and faith healers are in demand despite the risk of maltreatment (Read et al 2009). Meanwhile stigma and suspicion towards mental health services often means that for many, psychiatry is ‘the last resort’.

Then there’s whatever travel is required along hot, dusty, pot-holed roads to reach the more developed south coast where Ghana’s three psychiatric hospitals are based. This physical journey can be a significant undertaking in itself, typically achieved in sweaty, creaking, careening tro-tros, where it’s likely to be of little comfort for their passengers that daubed on the backdoors of these private minibuses are slogans of faith like God is My Provider or Amazing Grace. Furthermore despite numerous, similarly dedicated shops and literal advertising hoardings, ongoing reminders of life’s adversity remain evident among the eager roadside traders and hardship passed along the way.

Tro-tro stop outside Pantang Hospital

Such issues are relevant as many psychiatric medications and services are only available from the hospital, where further considerations are encountered. Here, while general health care is free, payment is expected for all prescriptions, investigations and the file that records each patient’s notes. All patients must also wait in the order they arrive, even for repeat prescriptions, as there are no appointment times. This may be further subject to handcuffed, police-escorted emergencies receiving intravenous Diazepam on a stretcher in the waiting area. Then when each patient’s turn comes, usually the most qualified member of staff they will meet is a medical assistant (MA) with limited psychiatric training.

Pantang Hospital outpatient waiting area

The Out of Programme Experience in Ghana

Although its unusual to find a UK psychiatry trainee in Ghana, I wasn’t the first to volunteer. The initiative was proposed by Professor Sheila Hollins in 2005 after her election as President of the Royal College of Psychiatrists. While previously serving on the College’s Board of International Affairs, Professor Hollins (a former VSO herself) and Professor Rachel Jenkins established the principle that out of programme experience (OoPE) placements by higher trainees could be approved for training. Subsequently Professor Hollins and John Rafferty, the chair for South West London and St George’s Mental Health NHS Trust, suggested Ghana as a potential OoPE location for the Trust’s higher trainees.

There were close associations with Ghana already as many of its nationals were Trust employees or resident in South West London, while its political stability and established psychiatric service were also important considerations. As Mr Rafferty also chaired Challenges Worldwide (CWW), an international development charity that arranges volunteer placements for professionals in developing countries, CWW helped develop the programme with the Trust’s Medical Director, Dr Deji Oyebode and Ghana’s Chief Psychiatrist, Dr Akwasi Osei. Additional support from the College and the London Deanery, as well as individual input by international psychiatry veteran, Dr Peter Hughes and Prof Hollins’ then Specialist Registrar, Dr Raj Attavar, were also vital for establishing the OOPE in Ghana [1].

At this time I knew Professor Hollins and Dr Attavar from my training with the Trust’s Learning Disability service and although the latter had hoped to volunteer himself, by the time the OOPE was approved, his training had ended. Fortunately, thanks to his efforts and of those above, there have been a number of successful placements starting with Dr Norman Poole in 2007, Drs Abdi Sanati and Olimpia Pop in 2008 and Dr Clive Stanton in 2009. Then after successful interview and approval from my employer, Sussex Partnership NHS Foundation Trust, I became their first trainee to volunteer, leaving behind the uncertainty of a post-election UK for a new world.

Pantang’s past and future

Pantang Hospital corridor by Greg Neate

On the rural outskirts of Ghana’s capital Accra, Pantang Psychiatric Hospital stands testament to both former pan-African ambitions and current reality. Opened in the 1970s as the country’s third psychiatric hospital, it was originally envisaged as a mental health village for psychiatry, neurology and neurosurgery serving all of West Africa (Asare, 2010). However like many of the grand, socialist visions of Dr Kwame Nkruamah – Ghana’s legendary first President who led it to independence from Britain in 1957 – the hospital’s scale of ambition wasn’t realised and now appears faded. Still, it remains impressive in scale with ten self-contained wards, a three storey administration block and a nursing school, connected by a large octagonal covered walkway that stretches across its extensive rural grounds.

Here mental health care for nearly 100 daily out-patients and up to 500 in-patients is provided by some 300 members of staff on site. However only two of them are psychiatrists as limited funding, poor career prospects and a ‘brain drain’ of professional emigration has meant that for a population of 22 million, there are just 13 psychiatrists in Ghana (Asare 2010). Thus while there were plenty of patients, I soon realised that my best role was providing teaching and supervision to Pantang’s three medical assistants (MAs), experienced nurses with two years of medical training who perform a much-needed doctor-like role.

I first met my new colleagues in the office of the Medical Director and former Polish national, Dr Anna Dzadey, where they all remembered my predecessor by six months, ‘Dr Clive’. Before I left, Clive had encouragingly described his placement as being his best training experience, though he added that finding time for teaching wasn’t always possible. Still, Dr Dzadey and I hoped that with the MA’s new rota – where two began in the mornings and the other covered afternoons – regular sessions could be arranged when their duties crossed over. However, as these Ghanaian men heard from their ‘lady boss’ about the relationship they would have with me, another European psychiatrist, the room did go rather quiet.

Ghana’s New Psychiatrist

Outside Pantang Hospital shop - photo by Emmanuel Amaglo

Initially I observed the MAs’ outpatient consultations, many of which occurred in English. If the patient and family only spoke Twi or Ga, then I followed what I could though it wasn’t always clear whether the MA knew the patient’s language either. Whatever language was spoken though, all clinical notes were written in English, which to my monolingual brain seemed an impressive transcribing skill.

To experience the work itself, I began to assess, advise and issue prescriptions myself, with a nurse translating when necessary. There was no shortage of patients and the staff appreciated how the waiting area was clearing. It all seemed surprisingly straightforward and when I saw previous entries by Clive and before him, Norman, I felt connected with a unique, shared experience.

However, there were also more serious decisions to make, like whether to approve hospital admissions. While some families came expecting their relative to be admitted, other patients were sent by the courts without advance notice. ‘What now?’ I asked Dr Dzadey, who advised that despite limited bed availability, we should support the family. Thus within days of arriving and my temporary medical registration approved, I was detaining Ghanaians of their liberty [2]. Furthermore, on the cover of these patient’s notes and under their name was now written that of their responsible clinician, ‘Dr Neate’; our names forever linked.

Providing additional supervision was Dr Peter Hughes, who as Director of the St George’s Higher Training Programme had previously overseen my annual reviews and supervised the previous Ghana OoPE trainees (Poole & Hughes, 2009). While securing reliable internet access for sending my written weekly reports was challenging at times, Dr Hughes always replied swiftly despite being in Haiti providing post-earthquake support. Although his emails lacked for spellchecks, they always emphasised that my contribution should be ‘sustainable’, particularly after I described seeing patients on my own;

“>>>In general clinic should be never with pateint and you only biut always should be trainign opportunity with MA or nurses . MAs could leaad clinic and you can sueprvise them. Not service job -training job”

Dr Peter Hughes, 14 May 2010 17:43:42

Assessing the Medical Assistants

Pantang Hospital outpatient nurses office

Lesson learnt, I spent one day a week with each of Pantang’s MAs starting at 8AM in outpatients, where evermore about Ghanaian society was revealed. Filling the centre of each consultation room was a large wooden desk with a large swivel chair on one side and mis-matched chairs on the other. A ceiling fan, an out-of-date calendar and a rarely used examination bed emphasised the importance of this healing centre. Sat waiting on benches along the corridor outside, patients and their families were expected to enter the moment they were called though rarely were handshakes and explanations offered. If the impact of this formality bestowed upon the room’s occupant an impression of wisdom and knowledge, well perhaps that was just as well.

Patients described physical symptoms of tiredness or head pains, while families were concerned that their relative was ‘over-thinking’ or ‘roaming about’. Some consultations ended surprisingly quickly while others passed in slow motion, as the MAs pored over limited notes and pursued unpromising lines of enquiry. Depression, anxiety and learning disabilities were all possible explanations though as many patients had long been unwell before their behaviour became problematic, schizophrenia was often diagnosed and typical (first generation) antipsychotics prescribed. Then, when follow-ups returned for review, there was little questioning of the original diagnosis or whether medication remained necessary.

It all seemed so different; the way the patients presented, how staff approached them, the family’s involvement – everything! Sometimes I’d feel compelled to advise the MAs to be more inquisitive or speed up a dragging consultation though I’d also remind myself of computer tutorials where the expert’s hands-off approach forced me to do things myself. I hoped that was possible here, yet these were actual patients and the MAs often appeared unaware of the risks involved. However, it was also clear that they were the only staff available to perform an incredible range of clinical duties, including specialities like child and learning disability psychiatry, as well as neurology and epilepsy. As if that wasn’t enough, I soon realised that many of the mobile phone calls they received during consultations concerned their external private work.

It was also noticeable that as there were few training or career opportunities for MAs after qualifying, there appeared little incentive for them to develop and improve their skills. Thus, with Dr Hughes’ encouragement, I began to assess their performance in clinic using a modified version of the Royal College’s Assessment of Clinical Expertise (mini-ACE) forms. While the MAs weren’t used to such evaluations, these provided a written summary of our work together. Later when my girlfriend, Wendy, visited we devised a simulated scenario of post-natal depression to standardise their assessments. Their more considered approach towards her demonstrated that they could raise their performance, though individual variations remained evident too.

I also conducted an audit of the MA’s work experience and learned more about their personal journeys. All had previously been nurses at Pantang who had undertaken MA training, nine hours travel north, at the Kintampo Rural Health Training School (KHRTS) and had now returned to live in hospital accommodation with their young families. Most approachable and vocal with his concerns was Mr Aaron Baah, whose professionalism was apparent though he was frustrated that being an ‘Assistant’ implied that he worked for someone else. In reality, he acted almost entirely independently, but because of his title, organisations wanting a doctor’s opinion didn’t recognise his.

That may start to change though as I saw while teaching on the Kintampo Project, a joint initiative between KHRTS, Hampshire Partnership NHS Foundation Trust and the University of Winchester. The Project intends to dramatically increase access to psychiatry specialists in Ghana by training MAs and nurses to provide services in rural clinics and rely less upon centralised hospitals. Thus, as well as being an exciting teaching opportunity for me, the Project’s graduates, including Mr Baah, may be among a new generation of mental health workers in Ghana.

Reviving the Rounds

Medical Assistant, Mr Ambrose Amenuvor and nursing staff on Ward 3

As part of my supervision of the Pantang MAs, I observed them perform clinical reviews of their inpatients in the afternoons. Here, across ten erratically numbered wards, each MA had a seemingly overwhelming level of responsibility that averaged over ten patients per ward. During Norman and Clive’s placements, both had arranged regular ward rounds to establish a routine of the MAs and nurses working together, though after they left these didn’t last long. Furthermore when the MAs did attend the wards, they lacked focus over who needed to be reviewed, while many chronic patients were overlooked. With Dr Hughes’ advice I suggested a framework for reviews of ‘diagnosis, social circumstances, goals of treatment and problems’. However, while supervising ten consecutive consultations of men with psychosis and cannabis use, I found that details would merge and even my own skills drifted towards Pantang’s baseline.

One issue I couldn’t help noticing was the severe extrapyramidal side-effects of some inpatients due to prolonged courses of daily intramuscular antipsychotics. I asked about Norman’s protocol for managing aggression which he’d introduced three years ago. Many people remembered his flowchart posters though they were no longer displayed and there were differing views among the staff about prescribing and administering sedative medications. Nurses preferred injections to ensure compliance, the pharmacy feared running out of supplies while the prescriber’s practices varied widely. What seemed necessary was a system that all could follow.

Norman Poole's Protocol for Managing Aggression

While this wasn’t resolved in my time, I did update Norman’s slide show presentation for Pantang’s weekly case review meeting, starting with a quiz before outlining the protocol and its benefits. With photographs taken from the notes of questionable accounts about injections, I described how the protocol’s steps aimed to deescalate and make safe differing levels of aggression. Although my intervention alone wouldn’t alter much, I hoped the principles of anticipating aggression would appeal and I reminded them of what could be achieved through negotiation as demonstrated by Ghana’s own global diplomat, former UN president, Kofi Annan.

In addition to my work at Pantang, I provided teaching on Friday afternoons for the MAs based at Accra Psychiatric Hospital (APH). Unfortunately their attendance didn’t always reward my two-hour journey by tro-tro through Accra’s haphazard roadworks and the day of the Black Stars’ World Cup quarterfinal wasn’t a successful one for teaching either. However, I was fortunate to meet APH’s Medical Director and Ghana’s Chief Psychiatrist, Dr Akwasi Osei, whose appearance, wisdom and manner has Mandella-esque qualities despite facing his own challenging responsibilities.

Insight into Insight

Elvis Akugmoar (head of eduction, seated on left) and student nurses at Pantang Psychiatric Hospital monthly meeting - photo by Clive Stanton

During his placement, Norman’s interest about how mental illness affects insight led him to research whether patients who denied their own mental illness could recognise mental illness in others (Poole et al, unpublished). Before my placement, we spoke about a new project to repeat a previous British study about insight (Startup, 1997) in Ghana. My main task was to take local advice about modifying the descriptions of mental illness that were used in the original study so these vignettes would be suitable for a group of English-speaking Ghanaians. I then field tested and validated them with local health staff so my successor, Dr Samanta Nagpal, could continue this research during her placement.

While the idea was intellectually interesting, its relevance was apparent when I saw that patients were often described as having ‘no insight’ if they denied their illness or refused medication. Having experienced other areas of ambiguity in Ghana, this seemed an appropriate subject to present at Pantang’s monthly teaching programme. Again, I began with a test and examples of descriptions of insight photographed from the clinical notes. I then outlined insight’s three aspects – illness recognition, relabeling experiences as abnormal and accepting the need for help – indicating how this often changes over time. To demonstrate this I invited a patient to attend the ‘grand-round’ meeting where she explained how her views about her family were factually true but not agreed by them, as parentage and sibship in Ghana are not always based on biological grounds. Thus while she was technically correct, she minimised the extent of her family’s concerns and later the audience questioned her inconsistencies.

Afterwards I heard it was the first time a patient had been interviewed during Pantang’s teaching programme and I hoped it would inspire further inquisitiveness by all. I was then presented with two Ghanaian shirts before I gave my own parting gift of handwritten nameplates for the staff to use on the outpatient clinic’s unmarked doors. Along with a wonderful leaving dinner with many of Pantang’s staff, this was my own good ‘good-bye’.

Summary

My placement in Ghana was the most fascinating and perspective changing experience in my psychiatry career. I particularly appreciated observing and participating in Ghana’s culture, which made me reflect on how I consider and teach psychiatry. I also appreciated observing the inner workings of Pantang, the interaction between all involved in mental health services in Ghana and witnessing the beginning of the Kintampo Project.

I am grateful to all who supported my placement, as well as those I met and befriended in Ghana. I will particularly remember feeling integrated within a country that was accessible and at times, curiously familiar. Yet Ghana was also unique, which despite its hardship has a generous, positive spirit where new surprising details were revealed every day. Back home, I have continued my Ghanaian associations and followed the progress of the Project as one day I hope to return, where I know a warm ‘Akwaaba!’ welcome is waiting!

Acknowledgements

I would like to thank all of those listed above who made this experience possible and so special. Drs. Anna Dzadey and Akwasi Osei, all the MAs, Elvis Akugmoar, Sahl Mohammed and the staff of Pantang Psychiatric Hospitals. Professor Hollins, Drs Peter Hughes and Raj Attavar, the London Deanery and the Royal College of Psychiatry. Daliah Houghton, Eoghan Mackie, Winnifred Oware and Challenges Worldwide. Drs Norman Poole and Clive Stanton and my fellow Ghana alumni. Drs Chris Aldridge and Glen Berelowitz, Sam Vaughan and Sussex Partnership NHS Foundation Trust. Dr Mark Roberts and all involved with the Kintampo Project.

Footnotes

[1] The Ghana OoPE is considered to be ‘cost-neutral’ as even though the Trust loses a trainee for three months, the London Deanery continues to pay their base salary. In turn each volunteer forgoes their on-call banding and London weighting, while one month of their salary is waived to fund CWW’s involvement and expenses such as medical registration and local accommodation. By registering as an international volunteer with the Royal College of Psychiatrists, trainees can also apply for funding for the cost of their flights.

[2] After numerous attempts to pass mental health legislation, there remains no formal mental health legislation in Ghana though the draft Mental Health Bill 2010 is under consideration. This bill aims to protect patients’ rights and ensure standards of care across orthodox, traditional or spiritual services (Asare, 2010) though delays and resources may limit its full implementation.

References

Read et al (2009) Local suffering and the global discourse of mental health and human rights: An ethnographic study of responses to mental illness in rural Ghana. Globalization and Health 5:13. [Accessed 10 October 2010].

Poole N (2007) Summary of Report on Ghana experience [Accessed 10 October 2010].

Sanati A (2008) Summary of Ghana Out Of Programme Experience (OOPE), [Accessed 10 October 2010].

Stanton C (2009). Summary of Ghana Out Of Program Experience OOPE, [Accessed 10 October 2010].

Asare, J. (2010) Mental health profile of Ghana. International Psychiatry 7, 67-8.

Poole, N. Hughes, P. (2009) A training experience to remember: working in Ghana, The Psychiatrist 33, 353-355.

Poole, N. Crabb, J. Osei, A. Hughes, P. Young, D. (unpublished) Insight, psychosis and depression in Africa: A cross-sectional survey from an in-patient unit in Ghana.

Startup M (1997) Awareness of own and others’ schizophrenic illness. Schizophrenia Research 26, 203-211.

Children within Pantang Hospital grounds

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