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The Royal College of Psychiatrists Improving the lives of people with mental illness

Southampton - Peter Adams

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30/07/2013 10:59:44

Assessing CMBO trainees on practical placement in Ghana

I’m feeling very inspired by my time in the UK.  Here I look at how we might be able to improve student assessment for the mental health courses at the College of Health, Kintampo.

Student assessment is an integrative component of the teaching-learning process in our schools and colleges and this is recognised globally as such. Assessing students on clinical placement is as important as other forms of assessing students in general. Clinical placement for students in the health professions is arguably the most important and useful way of ensuring that students acquire the requisite skills necessary for practice. It also ensures that students are competent enough to practice well. The extent to which students are deemed competent depends on the form, intensity and process of assessment.

The CMHO programme as run by the College of Health, Kintampo (Ghana), is a practical-based one with the curriculum document stipulating a 30/70 split (30% theoretical/classroom work and 70% practical/field work). At a Curriculum Review Meeting held at the college in February, 2012, it was agreed that this had not been achieved which was attributed to a number of factors including inadequate resident tutors, underdeveloped placement centres, etc. As a tutor on the programme I’ve been thinking whether we are doing enough by way of assessing students on practical placement and whether the outcome of the assessment is adequately factored into the overall assessment of the student. The students on placement are assessed by the preceptors (clinical and educational supervisors) who are mostly CPNs and RMNs with varied levels of experience and the scores from these assessments are entered in the students’ log books. When they return with their log books, what happens to these scores?  

Observing students on placements in the UK and taking note of their assessment procedures is quite revealing for me as tutor. Within the clinical setting there are three levels of assessment – peer assessment (informal but structured), placement-based supervisors’ assessment and school/college-based supervisors’ assessment. The last two, according to the students, count toward their final practical scores that will determine their level of competence in practical skills. Sitting in one of the sessions, I was impressed by the level of collaborative participation among the student and his supervisors. The student led the session by outlining his experiences for the week, his successes, challenges and what he was doing to overcome the challenges with time lines. From my perspective, I thought the supervisors were to provide some direct support to this student (as we usually will do in Ghana) but with a few thought-provoking questions the student was left to go and sort out those challenges.

The story was not different at the University of Winchester where I observed another practical session with medical students. Using role play, the lecturer began to take the history of a “patient” and suddenly stopped short then divided the students into smaller groups of four. The first group started from where the lecturer left off, and all the groups had their turns till the last group come in with their diagnosis. The interesting part of it all was justifications, criticisms, admissions and arguments (constructive) that ensued. The criticisms even started with the “patient” (whom I initially thought was a real patient because of the way he acted it out) with the lecturer assuming a passive role only coming in once a while with a thought-provoking question. A session of this nature I thought is key for us on the CMHO programme trying to achieve the 30/70 split that I mentioned earlier.

Finally, I was privileged to witness a preparatory session for two students who were referred in the practical paper. The first question for each of them was “what in your opinion were the causes of your failure even though you performed very well in the written (theory) paper? Each of them was then asked to explain his/her strategies to overcome the factors that caused their failure in the previous exam. They sounded positive and confident and they were told that they were starting them on grade B and that they could improve on it or drop. This I find motivating and reassuring for the students and capable reducing the anxiety associated with a lot of examinations. In a nutshell, the effective blend of practical placements, practical teaching approaches, students’ practical experiences and practical assessment practices as I’ve observed here in the UK is a sure way of achieving the training needs/goals of curricula such as that of the CMHO in Ghana. To achieve this in the Ghanaian context is something that I’m seriously wanting to do and your suggestions are most welcome.              


15/07/2013 09:20:58

Risk assessment and positive risk taking - Ghana

What is the role of risk assessment in everyday life, home, in illness and particularly in mental health practice? Obviously, all human actions and inactions carry varying levels of risks which consciously or unconsciously are assessed in various ways prior to those acts. In Ghana, decisions on health issues particularly mental illness come with higher levels of risks.

Risk assessment is a key component of deciding a management strategy for clients in our mental health facilities and even in our homes. For instance, family members have to assess the risk posed by an individual to decide where to access intervention (prayer camp, shrine or a particular mental health facility) and the type of intervention to seek. At the mental health facilities, clinicians and mental health practitioners also inculcate risk assessment in their approach to arrive at a decision as to how to intervene. But how do we perceive and assess risk? In Ghana, risk is often seen as the expression of the probability or the likelihood that something unpleasant will happen. So, it is always about the client will ‘disrupt’, interfere’, ‘harm’, etc. him-/herself, someone else or a particular event. This perspective reflects largely in most of the clinical decisions that we take in managing our clients.


Currently observing what goes on in the UK mental health system when it comes to risk assessment, I am beginning to rethink the meaning, purpose and implications of risk assessment by many clinicians and mental health practitioners in Ghana. With the current concept we largely hold in Ghana, I think there is a danger of risk assessments being unbalanced because we risk assess by just looking for “danger” and do not look for positive factors and strengths. Here in the UK, risk assessment is largely seen as an estimation of the likelihood of the occurrence of a hazardous event based on the awareness of the importance and presence of certain conditions that are assumed to be risk factors. Thus, risk prediction remains more of an art trying to make informed, defensible decisions about behaviour and not primarily about making an accurate prediction. Just because a plan has worked with no adverse outcomes, does not mean it was a good or safe plan and vice versa. Practitioners in the UK attach much importance to the fact that intervention on one risk can introduce new risks or increase risk in other areas. For instance, I happened to be shadowing a clinical psychologist on a team that discussed risk factors for the discharge of a patient (with self-harm) to the Hospital at home team. I was surprised to hear that they were giving the patient the opportunity to make use of the skills that he learnt whilst on admission at home. Here in the UK (unlike in Ghana), Practitioners use the terms ‘positive risk assessment’ and ‘positive risk taking’ to give the whole process a balance which I think is laudable.


I have come to appreciate that positive risk management practices could lead to identification of strengths of the individual, empowerment of the person, identification of alternative protective factors, effective support networks, integration of the perspective of all involved in the person’s care including the service user, etc. Also, the duty of care includes positive risk taking and learning from experiences including the consequences of different choices. In this way we in Ghana could move away from the strategy of total risk avoidance (since we focus mainly on the negative outcomes only) which in many cases lead to excessively restrictive management practices that may be contributing to the high level of stigmatisation and as a result the congestion that we are facing in our psychiatric hospitals. I’ll keep observing and thinking about this but if you have any ideas do let me know!



03/07/2013 10:18:04

Hospital at Home for Ghana

Congestion of our psychiatric hospitals in Ghana has been a long standing problem. Approximately, 650,000 persons in Ghana have a severe mental disorder and a further 2.17 million have mild to moderate mental disorders but only 2% receive any treatment. It is sad to note our country has only three psychiatric hospitals with bed capacity of 1200 for our 24 million people. 

A report released last year by Human Rights Watch described the psychiatric hospitals and some spiritual healing camps (which also treat patients) as “appalling”. The report said: “In the psychiatric hospitals, people with mental disabilities face overcrowding and unsanitary conditions”. Human Rights Watch noted that all three psychiatric hospitals were crowded and the Accra Psychiatric Hospital was severely overcrowded with many people spending all day outdoors in the hot sun. Several NGAs (Non-Governmental Agencies) in Ghana have appealed for a solution to the congestion.

One solution being tried is “Operation 600” whereby two years ago measures were put in place to repatriate 600 patients from the Accra Psychiatric Hospital who have been ready for discharge but have had nowhere to go. The long term plan however is to reduce bed numbers in the clogged mental hospitals and focus efforts on building community mental health services. A step in this direction has been the work of the Kintampo Project which has supported the introduction of the Clinical Psychiatry and Community Mental Health Programmes at the College of Health, Kintampo since May 2010. The passage of the Mental Health Bill in March, 2012 also drives the community programmes forward.

I have been observing the mental health system in the UK (Southampton) for two weeks now and I find it very revealing and interesting. Something I think could be very useful in complementing our efforts to rebalance our psychiatric hospitals to a more community focus is the concept of “Hospital at Home”. This service delivery system in which people with mental condition who would otherwise be on admission at the hospital, ‘admits’ people to their homes where they receive care as if they were on the hospital ward. The service provision is coordinated by the “Hospital at Home Team”. With this system, patients could spend very few days (sometimes not even a day) in hospital.

Accra Psychiatric Hospital has 600 beds but actually houses 1200 patients. Pantang and Ankaful Psychiatric Hospitals were turning away patients in March this year because of lack of space and funds, etc. The cost of running these hospitals is huge and uses up most of our mental health budget. 

People might argue there is a shortage of personnel, transport and other resources to implement  “Hospital at Home” but I still think it is a cost effective and appropriate idea to consider for Ghana. The cost of feeding the patients (which is borne by government) will be reduced drastically, pressure on physical facilities will be reduced, families will be fully involved in the treatment of the patient, social stigma is likely to go down, etc. Patients from far communities and acute cases would be given priority when admitting patients to the hospital wards and this will give the Hospital at Home Teams shorter distances to cover. I’ll keep thinking about this but if you have any ideas do let me know!



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        About this blog

 Peter Adams

Peter Adams is a psychologist and clinical tutor in Kintampo, Ghana. He is undertaking 8 weeks professional development in Southern Health NHS Foundation Trust, UK. His visit has been arranged via The Kintampo Project and is funded by a Professional Fellowship from the Commonwealth Scholarship Commission which is one of the largest and most prestigious scholarships schemes for international study in the world. This is Peter’s first time in the UK and he shares his observations of UK practice with you.