The Mental Health Reform devolving psychiatric care to local hospitals put forward by the Ministry of Health (MOH) is a step in the right direction although community mental health has had a controversial history. Mentally ill people deserve to be treated like human beings, have access to the best medical and nursing care and above all to be part of society. It has been shown in USA and the European world that community based approach is desirable (1) to prevent clients from becoming chronic residents of asylums with stereotypical stigma, (2) to resettle back in the community where they come from and (3) to be useful and contributory members of the society. So, the Ministry of Health and Quality of life is addressing something well over due and very noble but it is important that it learns from the experiences of countries like England, Spain, Holland, and Scandinavia. This reform presents Mauritius with a golden opportunity to be innovative, novel, ground breaking and way ahead of African and Western nations in mental health. This paper is a response to the MOH consultation mechanism white paper published by the Ministry?s website seeking feedback. It needs to ask some serious questions. Why community based approach and how community mental health concepts must be redefined? Where will the clients be? Who are the best healthcare professionals to care in the community? How will treatment be carried out in the community? Can all clients be treated in the community? What are the resources needed to launch and maintain a community based approach? What skills do healthcare professionals need to care in the community?

Community Mental Health

Community mental health is professional mental health care directed towards the maintenance of the Mauritian mental health; and the prevention of and management of existing and potential psychiatric disorders. It includes assessment of familial, environmental, social and personal factors which influence the mental health status of each and every citizen of Mauritius. The practice of community mental health is not only promotion of mental health at large but incorporates the identification of groups and individuals within the community who require help and support in maintaining and achieving optimal mental health. This is what it means when holistic care of the individual is the main target for professionals. Furthermore, the phrase ?our community? sometimes conjures up attributes such as giving warmth, comfort, caring, supportiveness and indicating positive help. The bitter lesson has been that not everybody in the community support mentally ill people and clients channeled towards the community have experienced varied levels of hostility and discrimination. Antagonism to having community homes in the neighbourhood is a regular feature in local and national press in countries which have gone down the community based approach.

Thus, my applause to the Ministry is that the strategy put forward is laudable but much more investment is required in public education. Community mental health is and must be the focus of the community. To secure the community?s support and warmth, the master plan of mental health reform must have ?Public Education and Removal of Ignorance? as the top priority. This should begin now even before the approval of the plan. The suggested reform will succeed or fail depending upon the amount of public education and publicity given to it. The public reaction can be a horrific one and is usually anti-resettlement resentment and the education process is a long arduous one. Thus, the earlier the Ministry gets itself in shape to educate, the better. It is only then that people will discover:

? Community as a social structure and its demographic features

? Community as a sentiment, as described by those living within it or by others about it

? Community as a social activity focusing on available amenities and resources

? Community as a locality

This is what community mental health is about. The features which will galvanise the community are: Culture, ethnicity, race and religion as a local focus. One must not forget the socio-economic background, level of education, occupation and the idiosyncrasies of the area of residence/region in Mauritius which contribute to group identity of local people. The other critical factors are: language spoken, past experiences and unemployment. These will add to the complexity of the community because mental health problems are not exclusive to the poor, uneducated and deprived people. Mauritius with its development and industrialisation has inherited an unfortunate fragmentation of the family unit. This has brought new forms of psychiatric disorders to those who aspire to developmental, materialistic and a faster and more sophisticated lifestyle. The common proliferating conditions are: anxiety states, depression, and addiction to cigarettes, drugs and alcohol, psychopathic and personality disorders.

Community Homes and Community Partnership

The advent of the community homes in England heralded a euphoric atmosphere of normalisation from asylums but also brought many concerns. The focus has been on small group homes and not institutions. Many clients with chronic mental health problems have been transferred to these homes and largely it has been successful. The reality is that mental health problems are not easily cured. So, relapses are frequent and clients need inpatient care and protection. The public needs protection and security too as people have different views about psychiatric clients. Some are just not suitable for treatment in the community and need secure environment. Thus, community homes suit a proportion of the clients, especially those with chronic neurotic type illnesses. Seamless care is difficult to provide when clients need frequent hospitalization and resettlement. The concept of community homes can become vulnerable and clients tend to become more apprehensive and confused about their long term care.

Community homes are best managed when relatives participate actively in supporting those receiving care. There is always a few cases of exceptions where relatives role are limited or denied. This is inevitable but the Mauritian culture is still viable in this type of partnership as the social structure of the family and extended family has not totally disintegrated. So, the strategy has to be heavily centred on:

l Fostering of good partnerships with relatives and voluntary groups. The person in charge of group homes has to be highly skilled in harnessing community support, in working effectively with local voluntary groups as well as statutory agencies. In care, close relatives have always been and will be the backbone of support if they are guided and counseled to play their constructive part in palliative and curative measures. Thus, community homes must not shy away from the public, business enterprises and interest groups. They can all strike a fruitful partnership for the better.

l Prevention of Marginalisation. Clients do get marginalized in any society especially if mentally ill, and hence there is a repeat institutionalization within homes. Clients should and must be empowered to be active residents of community homes, engage in self care gradually and play a huge part in its management and therapeutic activities. It is too easy for hospital routines and practices to be transferred to homes; and not too many professionals are good at transforming their existing hospital skills to suit home philosophy and practices. Thus, the focus of transition to a new concept is not only the clients but mostly the staff who need help, preparation and vision to make the conceptual leap to community based practices. Active Promotion of Psychosocial Health. This is a critical part of managing a successful home. Clients are members of society and a community. They have to continue their relationships with relatives, friends, and professionals and build new ones with the members of the home. Thus, they should not become recluse and ascetic in homes. There should be vibrant promotion of interactive techniques to enhance the psychosocial health. Reflective Group and individual methods should be used to build confidence and self esteem in addition to medical care. Professionals must realize that mental health is best promoted through psychosocial techniques with minimal medical therapies.

Education of Staff. This is critical for all grades of staff including the cleaner, attendant, nursing and medical staff. They must be skilled in modern techniques of caring for clients. Research studies in Finland have shown staff must have:

? Skills in delivering health promotion services and health needs assessment

? Refined interpersonal and counseling skills

? A strong grasp of professional ethics

? Evidence based care approaches

There is no doubt that public relations and securing the community?s support have proven to be integral in the UK. Therefore, staff should be able to educate the public, entertain the public and orientate the public in mental health care. This obviously requires a dynamic conceptual and cognitive outlook receptive to the public?s views, anxieties and efforts. In this respect, marketing skills are helpful. If staff is not educated and helped to transfer their skills into a home environment, the concept of community homes can easily fall into disrepute, lose vital community?s confidence and the whole scheme will be in disarray.

l Resources and resources. It is important that not only the Minister but the public realizes that community based approaches are very expensive. I am sure the Minister of Health is armed with a full costing of his proposal supplied by the health economists who should play a big part. Ideas of reform are useless without the political will and economic strength not only to fund this scheme but to see it through to its bitter and successful end. It is a resource intensive exercise. New buildings, new personnel, new ways of working, up to date education of all staff are all financially draining. But, it is time and is right that a successful society like Mauritius makes this commitment to mental health problem sufferers to bring dignity, respect and to restore their individuality in a modern civilized 21st century.

The Way Forward:

Public Healthcare Professionals (PHP)

The Mauritian proposal advocates employing a series of community psychiatric nurses (CPNs) to lead the reform. This has been tried and has shown to be less successful. It brings confusion about role boundaries among a gamut of professionals. Mental health sufferers need the help of multi agencies and they get very muddled, messed up and mixed up with differing versions of different healthcare professionals. Breakdown in communication has shown to be costly in resources, fragmented care and members of the public have paid with their lives. There has been patients wandering in the town and stabbing innocent people as a result of hallucinations and delusions, failure to take medications and lack of interagency cooperation.

There has also been a realisation that community professionals need a variety of skills. Frequent social visits by CPNs and administering medication has proved to be less effective. Scandinavia has progressed with the concept of public health nursing and has refrained from proliferating several grades of district nurses, health visitors, school nurses and so on like the UK has. However, England has just approved the emergence and registration of PHPs to undertake the care of people in the community. This will include care of people with mental health problems. Therefore, Mauritius could avoid a lot of interprofessional skirmishes and jealousy which community reforms bring. It is better to have one and only one type of professionals in the community promoting public health. Mental health care must be seen as part of public health and not an isolated practice for the mental health nurses only. It is timely, prudent and judicious for the Ministry of Health to revive the PHPs. PHPs are relevant, topical, change attitudes among carers, have a positive impact on care, remove interprofessional rivalry and discrimination issue and enable singular professional responsibility and accountability. My own publications on Higher Level Practices have called on the Nursing and Midwifery Council in UK to register Specialist Practitioners. I urge the MOH to innovate PHPs with Specialist Practice to give our professionals a career structure, retain Mauritian psychiatric nurses in Mauritius and our mental health sufferers the best chances in life.

Interprofessional Education and Training

The modern concept of healthcare education recognizes the need for a common foundation programme for all prospective healthcare professionals. It is absolutely important that the Health Reform has its central plank as HEALTHCARE IS A MULTIPROFESSIONAL AND INTERPROFESSIONAL EFFORT. It is erroneous to think that a nurse or a doctor works in isolation. The reality is that a person needs the help of several agencies to be in optimum health. The new concept in healthcare education acknowledges this fact and the education of all healthcare professionals must have a common menu of knowledge. England has already started educating medical and nursing students together and this will be followed by including physiotherapy, occupational therapy students. A common set of outcomes are being established and in this respect nursing has led the way in testing a set of competencies in Higher Level Practice.

PHPs will gradually replace all grades of staff in the health centers, community health agencies and public health bureau. This will ensure a uniform level of education in all sectors of public health including the hospitals (hospitals are part of the community and must not be treated in isolation). The main aim is to enable students of different sectors of healthcare to be together for the first year. They will study common core subjects in healthcare relevant to all sectors as outlined in the diagram below. The second and subsequent years will see a progressive movement towards specific education leading to chosen specialist fields. The new education programme suggested is as follows:

The PHPs are the future community health workers and the educational programmes must focus on the theory and practice of health, both mental and physical. In a developing and changing society such as Mauritius, they will need to cope with different expectations and demands. Thus, the PHPs need:

? Comprehensive skills and competencies

? Collaborative strategies

? Flexibility

? Versatility and readiness to adjust to changes

? Ability to prioritise

? Continuous professional development

? Ability to see wholeness of a client/family and service structure

? Able to work economically

? High level of efficiency and commitment

Private Enterprise

Community Homes need finance, new ways of working and high level of patient orientated practices. It has been shown that privately managed homes are cheaper and more cost effective. Staff is more willing to change practices in private homes in comparison to centralized government led homes. So, it is in the interest of the clients that the Mental Health Reform brings in the private enterprises with expertise and resources. Private home can be more creative and adventurous with the treatment and rehabilitation of the mental health sufferer because of its independence, less bureaucracy and local decision-making.

Mauritius owes it to the mentally ill to reshape mental healthcare and this is a unique opportunity to give the population what it rightly deserves. Private enterprises must be encouraged to revolutionise Mental Health just as the private hotels have done to our Tourism industry. To shy away from this opportunity, is to deny the mentally ill people the break and the prospect that they have been looking for away from the asylum.

Conclusion

PHPs are the new leaders of community mental health in this new decade. Mauritius will and need to become the leader in mental healthcare by implementing a system which will bring greater partnership between health care professionals and the community.

CPNs are yesterday?s agencies with limited success. Mental health must be redefined as a concept which belongs to public health and not institutional care. To enable this major transformation, the healthcare educators must innovate a dynamic, substantive and skill orientated educational programme to produce a new and efficient breed of PHPs to give the Mauritian people the highest level of care.

The Mental Health Reform must bring mental health problem sufferers into a civilized, respectful, and compassionate world. Mauritians deserve it and Mauritius must at all cost make this rightful massive investment to underline all developments with better care for our less fortunate. Mauritians around the world with caring skills and expertise must flock to our Island to help make this bold step successful.

Dr Taleb Durgahee, RMN, PhD Field leader in professional development

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