Summary of Ghana Out Of Programme Experience (OOPE)

June 2008-August 2008

By: Dr Abdi Sanati

I became aware of the programme in 2007 when Challenges Worldwide (CWW) presented the opportunity in one of the Calman Day conferences at St George’s Hospital.  One of my colleagues, Dr Norman Poole, was the first person to embark on this project in 2007.  Although I wished to apply at that time due to personal problems I had to postpone it. On February 2008 I applied to follow Dr Poole in the same programme and after a successful interview I finally arrived in Ghana on June 1^st 2008.  I had three main objectives when I applied for this assignment.  I saw it as a chance to contribute to the mental health care in developing world.  Working in a different environment and culture would be an invaluable professional experience.  And lastly, I considered it an opportunity for my development as a human being.

Background

This programme has been organised jointly by the Royal College of Psychiatrists, CWW and South West London & St George’s Mental Health NHS Trust along with psychiatric services in Ghana and the chief psychiatrist Dr Akwasi Osei.  The first specialist registrar who undertook the same programme was Dr Norman Poole whose report could be accessed on the Royal College’s website.

In Ghana, mental health services consist of three large psychiatric hospitals and some community services. The psychiatric hospitals are Accra Psychiatric Hospital (700 beds), Pantang Hospital (500 beds) and Ankaful Hospital (500 beds).  All three hospitals are based on the south coast of Ghana.  There are community services mainly involving community psychiatric nurses.  Also there are additional services by Non Governmental Organisations (NGOs). Patients and their families also use prayer camps and traditional healers quite frequently.  The clinical work is provided by psychiatrists, psychiatry residents (doctors in postgraduate training for psychiatry) and medical assistants (MAs) – nurses who had undergone an extra year of training that enabled them to make diagnoses for common mental disorders and prescribe medications.

I was mainly based at the Accra Psychiatric Hospital for my clinical and teaching work.

Clinical Work

My clinical work included both inpatient and outpatient work.  In Accra Psychiatric Hospital the focus was more on outpatient clinics run by doctors and medical assistants. On a typical day at least 2 doctors and 4 medical assistants ran outpatient clinics.  On the other hand I observed the inpatient wards had not been receiving the same standard of care as outpatients. Therefore I decided to focus my work mainly on inpatients.

I ran two outpatient clinics a week.  The clinics started at 8 AM and would continue until the last patient was seen.  One clinic was allocated for the new patients and one for the follow-ups, although I invariably ended seeing a mixture of both.  The number of patients attending clinics was considerably higher than in the UK and saw more than 5 new patients and several follow-ups in one morning. The range of clinical problems also varied significantly and I had to manage headaches, epilepsy, malaria, typhoid fever, even skin conditions, in my clinic.

In the inpatient work I first had a review of all the wards.  There were 24 of them in the hospital and I decided to focus on the busiest ones which offered the greatest potential for development.  The Accra Psychiatric Hospital is a 700 bed hospital which currently has 1200 inpatients.  These patients were not evenly distributed in the wards and some of the wards were especially overpopulated. I wrote a timetable for my ward reviews and visited different wards according to that schedule.  Initially it was difficult to accustom the ward staff to my timetable but after a few weeks they all knew my schedule and prepared cases for me to see.  I especially asked for patients who were an inpatient for a long time and ones who had not been reviewed for more than a month.  Unfortunately, that included a large proportion of patients. There was an unwritten rule in the hospital of not discharging any patients without a family member to take them away.  Frequently I came across patients left in the hospital by relatives with nowhere to go.  The hospital administration allocated a separate ward for these patients and the Welfare Office was trying hard to find the relatives and facilitate discharges.

The resources at my disposal were scarce. The medication list was as follows:

           Antipsychotics: haloperidol, chlorpromazine, depot modecate

           Antidepressants: amitriptyline

           Anticonvulsants: phenobarbital, phenytoin and carbamazepine

           Benzodiazepines: diazepam

           Mood stabilisers: carbamazepine

           Anticholinergics: benzatropine and benzhexol

While I was there a stock of olanzapine arrived and we started using it.

There was one clinical psychology department where there were two to three clinical psychologists working.  I managed to have a good working relationship with them and use their experience in helping my patients.

In my ward work I tried to involve the nurses in making decisions for the patients.  Initially some were hesitant but gradually they all contributed more.  I had the opportunity to hand over to my successor Dr Olimpia Pop so the practice will continue and the staff will feel more involved in decision making.

I asked the MAs to follow me in the ward reviews and after a few weeks asked them to see the patients and observed them.  I gave them regular feedback on their clinical work.  I continued observing them in both inpatient and outpatient settings and received positive feedback from the MAs.

Teaching

I did one session of teaching a week for the MAs.  Each session lasted 2 hours.  The time for the teaching was protected and it was explained to them they should be free of clinical duties to attend the teaching.  I had the support of Dr Akwasi Osei for the time protection.

For the topic of teaching I asked the MAs to choose the areas they believed they needed improving.  They all chose mental state examination and psychiatric symptomatology.  I employed techniques I had learned in my CPBL training and also used role playing and case vignettes. At the end I asked them to fill feedback forms and the feedback was very positive. The teaching is continued by my successor at the same time every week and a routine has been established.

In order to make the teaching more attractive we managed to arrange for the MAs to receive a certificate from Southwest London and St George’s Mental Health NHS Trust.

Research and Audit

I conducted an audit on the quality of prescriptions in the hospital.  The month of April 2008 was randomly chosen and all the prescriptions issued in that month were reviewed.  The results were presented in an academic meeting at the hospital.  It needed liaison with the pharmacists and clinicians.  I recommended conducting a prescription workshop for all the clinicians and pharmacists.

Electro-convulsive therapy is a common modality of treatment employed in Accra Psychiatric Hospital.  In the last 10 years the average number of ECT treatments has been 1821 per year. The diagnoses include schizophrenia, bipolar affective disorder and depression.  I did a survey on the ECT practice in the hospital with specific focus on patients with schizophrenia.  I presented the results in a poster in the 4^th International Mental Health Conference in London on my return.

Other activities

I attended the African Association of Psychiatrists and Allied Professionals (AAPAP) conference in Accra. I found the conference very informative.  During the conference I met several professionals from around the world involved in research and teaching in developing world.

I received regular supervision from Dr Osei.  Every week I sent a weekly report to my educational supervisor, Dr Peter Hughes in London.  I received constant support during the assignment from my colleagues in Ghana and UK.

Benefits and Challenges

I found the whole placement very beneficial.  Overall I achieved the goals I had set for myself.

I managed to make some contributions to the mental health services in Ghana.  I believe by teaching the MAs and making the teaching regular with protected time the hospital can benefit in long term.  The audit I conducted raised awareness of some of the problems and the potential to solve them and excel in the practice of prescribing.  Clinical mentoring of the MAs helped them to improve their clinical practice.

In my professional development I found the experience invaluable since I had to cope with much more work with fewer resources.  Also working in a different culture needed due acknowledgement of the sociocultural factors operating in the aetiology and management of mental disorders.  A different culture meant different ways of communication with patients and family members.  Adapting to the new environment was both challenging and rewarding.  The process of work was very enjoyable.  The cooperation from the staff was more than I expected.  Also the patients were very appreciative.  Despite not having sufficient resources I actually felt I was doing more for them than I expected.

The personal experience of being in Africa was even more rewarding.  Learning about people of a totally different culture, living with different customs, eating different food, all gave more flavour to my time there.  I found Ghanaians very easygoing and cooperative.  I never felt a stranger despite looking different.  I had a very friendly landlord and I felt at home during my stay there.  At the end I started enjoying very hot Ghanaian food and that opened a new avenue for my taste buds to explore.

The experience was not without challenges.  Managing the cultural shock of another country was not an easy task.  Also there are certain aspects of practice there that are very different from UK.  The pace of work is slower.  Change is not very welcome and I had to overcome the passivity I encountered among the staff.  Like my predecessor, I had to deal with some legal issues without a Mental Health Law to refer to.  Managing physical illnesses put some extra pressure on me especially considering I had not managed them independently for years. Working with under-trained staff was another challenge to deal with especially when it came to control of aggression.  They did not have training in control and restraint and I had to highlight this issue for the chief psychiatrist.

Recommendations

• It would be helpful if the SpR spends a day a week at Pantang Hospital to clinically supervise the MAs there. I discussed this issue and it was agreed and implemented.
• Visiting Ankafoul Hospital at least once to give some supervision for the MAs there.
• Future discussions about the project should focus on achieving greater effectiveness of short placements and continuity in the programme overall.

Acknowledgements

I wish to thank everyone who has been involved in making the experience possible: Dr Peter Hughes, Eoghan Mackie, Alison Denny, The Royal College of Psychiatrists, Challenges Worldwide; all the staff of Accra Psychiatric Hospital especially Drs Akwasi Osei, Sammy Ohene, Yomi Fashola, Ajua Appau and Chris Danso, all the Medical Assistants and last but not least the people of Ghana for their hospitality.