Ghana placement

Ghana- 14 May 2007 – 10 August 2007.

The work-plan was created by CWW in collaboration with Dr Anna Dzadey (Chief Psychiatrist, Pantang Hospital) and Dr Akwasi Osei (Acting Chief Psychiatrist, Mental Health Unit, Ghana Health Service). 

The work over 3 months was primarily based at Accra Asylum (800 bed) and Pantang Hospital (500 beds) in Accra. The work was split between Clinical work, Teaching and Research.   I also undertook ‘Outreach Clinics’ with Basic Needs in Tamale in the north of Ghana.  Mentoring support was provided by Dr Osei, and Dr Peter Hughes (SWLSTG Trust)

I really enjoyed my time in Ghana.  My report outlines some of the challenges with the original work plan and makes recommendations for future placements. (things to cover in training/ work plan focus).   Part of how I was able to cope with the challenges of working in the hectic and sometimes overwhelming environment in Ghana was the recognition that I was part of a bigger programme.  I was there for three months so I couldn’t be expected to change it all and make it all better.   I could focus on the small changes I could make and the support I could provide to the medical staff on a one-to-one basis.  I have also seen how future 3 month placements over-time could make a real change to the delivery of mental health services by building and developing on some of the changes to practice I have introduced and focussing on developing a programme of on-going training for Medical Assistants. 

1)    General report on experience from workplan

1.1 Clinical Work:

Clinics: 5 sessions each week for clinic work. Busier than the clinics SpRs do in the UK, but not overwhelmingly so, with greater proportion of patients with psychosis and epilepsy. Focussed mainly on the MSE, social history, collateral history and physical examination.  On the first day Dr Dzadey requested that a rota system for clinics be introduced. Unfortunately this did not run particularly well. Some doctors took it seriously, while others did not.

Ward work: There is no protected time for Dr’s to do this.  The wards were fairly basic with low staff to patient ratio. Despite this I rarely witnessed aggression. When it did occur the aggressor was heavily sedated. The standard combination was 150mg of IM chlorpromazine with 20mg of IM or IV diazepam.  Admitting to wards from clinic easy. Bed always made available if necessary. No Mental Health Act here so I used capacity test when patients unwilling to be admitted. The family are able to give consent for admission and although this is the general practice it made me feel uncomfortable. The nursing staff seemed initially sceptical of my treatment strategies, particularly using lower doses and using just one antipsychotic. However, by the time I left I felt welcomed and valued on the wards.

Chronic wards: I initiated ward rounds there as teaching aid for the Medical Assistant Emmanuel and to allow the ordered review of all the patients there. During initial process it took three to four hours each week is we went through patients notes and MSE closely then the patient was brought to the ward round table. I wanted to make it as multi-disciplinary as possible and involve everyone in the decisions. I felt the charge nurse really responded to this approach and he began to give good advice and was very methodical in his approach. To begin with I did notes / interview / decisions, then progressively handed over these responsibilities to the MA. By last month he was doing all and I sat as observer to be called on if needed.

The Charge Nurse told me that the introduction of ward rounds had made a “big difference”. Violence reduced, less psychotic behaviour, a few discharged, and more absconding (I am unsure if this because patient less psychotic so made good their escape, to avoid treatment, fear of white doctor, or external factor such as food shortage), happier place to work, ability to get on with more nursing type duties. I asked to give MA a boost, but it was a real boost for me. I remain impressed that a small change to a system can have a noticeable effect.

1.2 Teaching:  I prepared 1 hour teaching for most of the weeks I was based at Pantang. The topics covered were mental state examination, cognitive and frontal lobe examination, delirium and chronic confusional states, schizophrenia and its pharmacological management, depression and its management, epilepsy and its management, and identification and management of acute aggression.

The MAs were keen to attend but there is no protected teaching time. They engaged well but do lack knowledge. The only psychiatric training they receive is on the MA course. Little ongoing professional development and the training they require is more basic than I expected.

I had a real problem engaging with the doctors. One turned up for teaching only once. Initially I had thought the teaching would be a big part of the work plan but despite Ghanaian promises to the contrary there is no culture of weekly teaching, case presentations or journal club.

On my penultimate day I delivered a protocol on “The Management of Aggression”.  The nursing staff appeared interested and the protocol, which aims to reduce excessive tranquilisation, was the cause of much debate. Despite the challenging nature of this presentation I was warmly and respectfully received and this felt like a “good ending”.

I have provided information to Challenges Worldwide about the teaching element of the work plan and have discussed my ideas for ways to incorporate this for future assignments.  Teaching would be most effective focussed on the Medical Assistants and CWW plans to develop this further, looking at protected time with the GHS.  (see collaboration below)

1.3 Research: The research project that it was planned I become part of did not materialise.  As a consequence I had to come up with an idea very quickly and produce a protocol. I became interested in insight in psychosis because many patients seemed to lack insight but agree to medications. The large number of psychotic patients with reasonable English makes this a good place to carry out research. The sample are different from those in the UK because they have longer periods of untreated illness and more negative symptoms secondary to institutionalisation.

The study protocol was quickly passed through the local ethics procedure and I left with data on 51 psychotic inpatients. I was helped in the data collection by Dr Jim Crabb. The ward nurses also played an invaluable role by quickly gathering all those patients with known schizophrenia and a good command of English.

I have provided information to CWW on the Research element of future placements and would be keen to co-ordinate this. 

1.4: Outreach Clinics: The outreach clinics began in Wa then we visited four other locations. They announce arrival of an “expert” on local radio and churches for weeks before. People walk 60km to come visit you. I saw between 10 – 72 patients a day. This was tiring, challenging and monotonous.  I felt the experience was most rewarding when I could sit with the local psychiatric nurse who knew the patient and discuss the management plan with the person who would remain involved with the patient. When the clinic is very busy the nurse helps review known and uncomplicated cases.

I also visited traditional healers supported by Basic Needs. BN help with money for food and clothes if the traditional healers agree to alter practices, such as beating and burning. I was surprised how similar their beliefs are to the western biopsychosocial model. They focus on present state, recent life events and family history but are less interested in developmental aspects.

Treatment is supportive asylum in the camp. Use herbs to calm the patient. They believe giving the patient a chance to talk is helpful because no one else listening. They still shackle patients in early stages to prevent them absconding. They believe all MI is treatable. Difference between them and Psychiatry is that they can cure while we can “treat”. If their treatment fail or their suspicions are roused because they start to feel the need to ask certain spiritual questions, then they decide this is spiritual. The treatment involves burning phrases from the Bible or Koran, depending on their own belief system. One healer may use spiritual treatments and receive referrals from others who do not.

They were keen for psychiatry to get involved and to help manage those patients they are struggling with. These camps serve a useful function in that the GHS could not cope with the influx if they closed down.

The camps are the first resort for a large section of the population who share the belief system. Despite seeing a shackled patient I was impressed with the care offered. The shackled man seemed happy and was clearly on good terms with his “captors”.

I also met up with Dr Adjase, the director of the Medical Assistants program on my way back south to Accra. Very friendly and keen to collaborate in this programme.  Would like us to begin with a post-grad course for psychiatric MAs then start thinking about undergrad MAs. (see above). 

2) Mentoring and Supervision.

My UK Mentor was Dr Peter Hughes who was my consultant in the job I left to go to Ghana. I emailed Peter each week to tell him how each of the areas (clinical, teaching and research) were developing and also to inform him of my thoughts and experiences. Peter has worked in Africa before and I found his input useful and encouraging. He was aware of issues that could and did arise and offered his support and advice. When working in Ghana I ruminated over the work much more than I would usually do in the UK and I often looked forward to receiving Peter’s thoughts.

Ghana mentor was Dr Akwasi Osei. I saw Akwasi for 1 hour supervision every fortnight. This felt about right. I also kept Akwasi informed of the projects progress and found discussing cultural aspects very useful. Not just the differing presentations but also the different attitudes to illness held by patients, their carers and also professionals. I found Akwasi to be very supportive of the project and myself and felt comfortable discussing difficult areas, such as my own sense of “not being thorough enough” while balancing this with “not being too slow”. I also discussed the future direction of the project and Akwasi agrees we should help to develop aspects of Pantang and the MA program.

3) Benefits from the assignment

a)     Changes have been made and noticed. That is very satisfying. It has taught me that psychiatry is as much about creating a robust system as understanding each individual.

b)     Learning about new culture, which will also help in my work as a psychiatrist in the UK.

c)     I felt welcomed and appreciated. The staff asked if I would return and if the program was to continue in the future. The experience was varied and challenging.

d)     Patients rewarding and grateful. Its unusual in the UK to feel so appreciated.

e)     New avenues have opened up for the program to explore. With seemingly little pushing our colleagues in Ghana genuinely want to work together and develop psychiatry in Ghana. The MA program is one such example.

f)       Supervision useful and enjoyable. Dr Osei guided me through the cultural shocks and was supportive of me. It was useful to discuss my anxieties about not working as quickly as the Ghanaian doctors.

g)     Learnt about myself – pragmatic, able to cope in a new environment, able to work with others. Learnt new way off dealing with others: don’t rush into business, take time and don’t rush, remain friendly and cheerful even when stressed.

h)     Pantang is a very good resource for those wishing to do research. An SpR could leave with a moderately sized study that would probably take the whole of their SpR training to conduct in the UK. If somebody agreed to co-ordinate this research and build up a database then some significant research would accumulate over the coming years. For example my research into insight could be expanded by looking at frontal lobe functions or health beliefs depending on the next person’s interests.

4) Challenges I faced during the assignment

a)     Teaching culture not established in Pantang.  I wasn’t aware of this for the first few weeks.

b)     Need to pick up cultural aspects as you go along.

c)     Developmental role will take time to be recognised as a priority locally. The clinical work is easiest to engage with because it is so visible. It would be easy to focus exclusively on this, and staff would be happiest if we did.

d)     Working with a doctor who I have concerns about.

e)     Problems with health care mainly basic – No effective rota system, physical health aspects under recognized, in-patients not reviewed, and drug supply inconsistent.

f)       No introduction to mental health law, cultural aspects, local procedures & policies or medications. With knowledge gained this could be introduced in pre-departure training.

g)     Accra is fairly expensive city to live in.

h)     Pantang far away from anywhere you might want to live, travel is either time consuming and uncomfortable (minimum of 2 hours each way in a local bus) or expensive (taxis there and back will cost £10 per day).

5) Recommendations for next stage/ overcoming some of the challenges

a)    Return to Pantang Hospital to continue clinical and developmental work.

Clinic work, 3-4 sessions a week.  Ward work – 2 sessions a week. See acute patients, and develop chronic ward.  Service development, half a day a week.

Service Development suggestions:

i.                    Develop rota system for clinics and ward work or an on-call rota.

ii.                   Develop Kardex system.

iii.                 Develop Alert system for in-patients

iv.                Develop in-house teaching program i.e. CP and JC (but not to do it all).

b) Develop MA post-grad curriculum Must cover core topics. Should avoid anything too sophisticated and focus on how mental illness should be managed with the available resources. Ideally half-day per week release scheme. The MAs from both Pantang and Accra Asylum should be included. Perhaps the Royal College could consider creating a certificate upon completion of the course because professionals do like such tangible things. Cover topics theoretically but focus on cases and case management.

c)  Clinical supervision of MAs - Doing ward round together. Sitting in on their clinics to discuss cases and Management.

d)  Bolster Basic Needs work in the north - Visit the northern regions more regularly, perhaps twice in the 3 months. See if more collaborative clinics/teaching can be developed.  I would avoid BN in Accra. Clinics too busy and no potential there for us to develop.

e) Liaison work with traditional healers - Could incorporate cultural studies at TICCS.

Cover arrange with the clinics in the North.

f) On-going contact to Dr Adjase to see how the undergrad MA course can be developed. Find out what topics covered and need to be covered.

Because my focus here has been Pantang, and there are clear areas for development here along with a demonstrable willingness to collaborate, this should form the bulk of the next stage. But attention should also be given to those other areas which offer the potential for new and challenging work.

Dr Norman Poole - September 2007

Dr. Akwasi Osei, Acting Chief Psychiatrist, Ghana had the following to say on the pilot programme

“I think the programme was a success and mutually beneficial. Definitely we can grow it and it would even get better with time.”

To read more on the feedback from Challenges Worldwide and Dr Poole's UK mentor please click on the links below.

Report from Challenges Worldwide

Report from Dr Peter Hughes - UK mentor