Mount Carmel Mental Health Hospital’s Framework

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The Republic of Malta is a small three-island archipelago country located in the Mediterranean Sea. Consisting of a population of just over 500,000 people, the country is one of the smallest ones, maintaining a close sense of community. In the context of mental health, there is only one operational psychiatric hospital currently. Furthermore, mental health has been greatly stigmatized in Maltese society, leading to poor treatment and ongoing problems. A recent 2019 publication of a national mental health strategy for Malta demonstrates first steps in shifting perspectives, both socially and economic investment into psychiatric care. This paper investigates the application of the national mental health framework at the Mount Carmel mental health hospital and organisational elements and changes that have been applied.

Mount Carmel Hospital was opened in 1861, named after a Catholic legend and famous altarpiece in the Valetta Church, as Our Lady of Mount Carmel remains one of the most widespread devotions in Malta (Agius et al., 2016). It remains the only hospital with in-patient psychiatric and mental health care in Malta after the closing of the psychiatric unit at Mater Dei Hospital in 2020, and the construction of a new mental health hospital is completed in 2025. Mount Carmel is more than 160 years old, resulting in the hospital being significantly outdated, both in terms of physical infrastructure and its facilities due to relative lack of investment from the government (Calleja, 2021). The facility is large with multiple wards ranging from regular care to juvenile or elderly patients to incarcerated or special needs patients. Unfortunately, wards are being closed down for refurbishment without reopening due to lack of financing. However, the total bed capacity at the hospital is over 200 beds. Mount Carmel offers both in-patient and out-patient mental health services (Pace, n.d.).

Until recently, mental health has not been a priority in Malta. Despite having a free and developed public health system and government commitment to social protection, mental health has historically and culturally been viewed with a stigma. Mental health care provision is under the same organisational system as general health, but only 9% is allocated to psychiatric care. Most of the services are through the free national health service, but private entities do exist on the island (Galea & Mifsud, 2004). However, physical and mental health have been viewed as dichotomy, separated by artificial barriers, stress differences and support stigmatization. The disregard for mental health services can be seen in the very poor state of Mount Carmel hospital (Times of Malta, 2021). To date, there is a lack of comprehensive statistics regarding mental health prevalence and illnesses occurring on the islands. Among European countries, Malta has one of the highest numbers of psychiatric beds per 1000 population (Lia, 2017).

In 2012, the Mental Health Act was passed in the Maltese legislation that sought to reflect the latest changes in knowledge, medical and social developments regarding mental health. It also created a new position of the Commissioner for Mental Health as a monitoring and governing body. It is the first legislation in Malta providing rights to users and carers in the mental health sector and guarantees that those with mental health problems are considered full citizens (Buttieg, 2012).

Under the first Commissioner John Cachia (2012-Sep. 2021), gradual changes began to be implemented as outlined by the Mental Health Act and his own vision. The country is in the process of reforming, renovating, and enhancing it s mental health services. In accordance with latest research, a greater emphasis is now shifting to community services and resources, through small local mental health facilities or help centers, alongside with building a new fully financed and developed psychiatric hospital (Grech, 2016). It is largely due to Cashia’s efforts that mental health issues became more visible and discussed in Maltese society, emphasizing the shortcomings of the services and evident gaps in the country’s system. The relationship between society and mental health remains delicate, but there is significant progress (Times of Malta, 2021). Despite these advances, Malta severely lacks human resources in terms of mental health professionals to address the country’s needs (Lia, 2016).

As the COVID pandemic with subsequent lockdowns began to have profound effects on mental health, the Mental Health Strategy was launched in 2020. It is part of the overall health strategy for the community which is critical. The publication demonstrates that the government has “embraced the notion that there can be no health without mental health,” with the need for integration of all health services (Times of Malta, 2021, par. 5). It reflects the developments of recent years and processes and goals targeted by the government in mental health care provision. Overall, the strategy seeks to uphold values such as autonomy, dignity, and rights of people with mental health, recognizing the need for equal opportunities and access to appropriate healthcare. The strategy is meant to guide the implementation of investments and reforms to the mental health system in the country. Its central tenet is resilience, that of individuals, organisations, and communities making them stronger and empowering the population. The strategy also seeks to identify and focus on the wider social factors leading to mental disorders or affecting their perception or treatment (Office of the Deputy Prime Minister Ministry for Health, 2019).

Therefore, the adoption of this National Mental Health Strategy is a result of various influential factors and years of work by mental health advocates.

The theoretical framework selected to review the implementation of the mental health strategy is PESTEL. The PESTEL analysis for Mount Carmel hospital after adopting the framework can be seen below:

Political	The support for the new framework has stemmed largely from the politics of the current leadership. Without their political will and instruments, it would not have been possible. Therefore, the framework strongly relies on the current political status quo continuing and funding stemming from the government to continue financing the major reforms.
Economic	Both developing and implementing the framework is highly expensive at all levels, including country-wise and at the Mount Carmel hospital as well. The hospital relies on government financing as well as private service utilization that it offers. Budgeting and spending have to be carefully accounted for to maintain operations and infrastructure. From a societal perspective, mental health is something that gets disregarded when economic crises are involved, even though it is when it is perhaps needed most.
Social	One of the primary elements of the framework has focused on social education and acceptance of mental health to reduce stigma. It is critically important for implementation that the process continues, and de-stigmatization occurs in Maltese society in order to stimulate utilization of mental health services and for those that need it, they are able to find help at a timely manner from quality healthcare provision.
Technology	Technology contributes to both service delivery and health services. Modern imaging technology helps to accurately diagnose abnormalities in the brain and study it carefully for most effective treatment possible. Meanwhile, technology is helpful in providing greater access for Maltese people to services and information. Particularly during the pandemic closures, mental health aid can be received via telehealth in mild cases or where counseling is necessary. Using technology and the Internet, people can read more about mental health from official public health and government sources as well.
Environment	Environmental factors may impact the implementation of the framework or the ability of the hospital to provide services. There are contexts such as the pandemic, major weather events due to climate change, and others which have effectively cut off health provision, especially mental health services which are oftentimes seen as non-essentially. Notably, these many environmental factors can also cause stress in the population, leading to a greater prevalence of mental health disorders in Malta.
Legal	The national framework is a legal document and serves as not just guidelines but as a mandate as well to make the necessary shifts in the next decade in terms of mental health care provision. The hospital itself has to legally protect itself when providing such nuanced services, there are regulations which must be followed to maintain licensure.

Initially, staff was sent out a newsletter announcing that major changes were arriving to the organisation and asking for patience and collaboration. Managers were called in for training and meetings. Eventually it became known the hospital plans to introduce changes consisting with the Mental Health Strategy. The CEO along with management staff chose to use Kotter’s Eight Step Change Model to guide the change management process. At a large staff meeting, the CEO presented a passionate speech, identifying gaps in the current system and outlining the benefits of adopting the new framework, fulfilling the first step of “create a sense of urgency” (Kotter, n.d.). For the second step, “build a guiding coalition,” the management team brought in experts who along specifically selected representatives from each position (physicians, nurses, management, etc). This group presented their insights to contribute to effectiveness of changes in the hospital. With the third step, a strategic vision was formed alongside initiatives. These were already outlined in the Mental Health Strategy, such increasing quality and access to mental health services. The fourth step was communicating the vision and garnering support, which was largely accepted. Most staff in the hospital wanted the best for the patients and realized the poor state that the facility was in, needing change.

The fifth step was to remove obstacles. This consisted of removing any negating elements or unsustainable practices. It was made sure that organisational processes and structure meet the vision, so new standards were established in how patients are received, treated, and discharged. Those that resisted change were encouraged while those who supported it were endorsed. For the sixth step, short-term wins were created by seeing an improvement in patient satisfaction scores after implementation and the general mental health treatment approach seemed more efficient. Finally, the seventh step is consolidating gains, management sought to collect employee feedback on the experiences with the new changes, the reflections helped most realized that significant steps have been taken to improve the hospital, and as more funding will come in via the framework, the physical conditions of work and patient treatment will improve as well. The eighth step of Kotter’s model will be discussed later in this paper in the context of organisational culture. In the context of the Mental Health Strategy implementation, the Mount Carmel Hospital also sought to work with the government, local communities, and organisations such as the Maltese Association of Psychiatry, to both, gain expert guidance on internal changes but also work collaboratively on one of the main components of the National Strategy, which is community outreach and mental health services. Analysing the Mental Health Strategy in retrospect and how it was implemented, the policy inherently sought to encourage and improve collaboration when it comes to mental health service provision or general societal work on the topic. It is vital to improve care across boundaries to enhance care. It is important to consider on of the primary aims of the strategy which is to remove any artificial barriers between physical and mental health. Therefore, no matter what is being treated, physical or mental health, patients seek to receive responsive and holistic care. Fragmented health system treat patients’ problems in isolation resulting in poor outcomes. However, working across organisational and even specialty boundaries bridges traditional divides improve patient experience and does not overburden professionals (Coughlan et al., 2020).

Strategic leadership was critical in the adoption of the National Strategy, both from an organisational and management point of view as well as the cultural changes. The Mount Carmel Hospital CEO Stephanie Xuereb oversaw the implementation and took strategic lead in making concrete changes to the hospital. The management team with Xuereb at the help sought to develop a plan that would bring about cultural and protocol changes for the whole organisation while reconfiguring the mental health services network in accordance with the National Strategy. Xuereb’s priority is to make tangible improvements in patient care across the mental health spectrum, making it patient-centred and easily accessible (Azzopardi, 2021). For healthcare organisations, strategic leadership typically involves setting and working towards them, with an emphasis of increasing quality of services, efficient workflow, and managing the hospital so that it is on a sustainable trajectory (Ogamba & Nwaberiegwu, 2020).

Healthcare is constantly changing, but despite this familiarity, navigating change and change management is an extremely complex endeavour. The changes arriving with the adoption of the Mental Health Strategy for Malta were extensive, through frameworks, protocols, training, and general attitudes. The presence and actions of strategic leaders at this time is crucial for the success of change management implementation (Riwo-Abudho, Njanja & Ochieng, 2012). Xuereb undertook various strategic actions. First new performance goals were developed and introduced, alongside a performance appraisal process. These goals were not the basics expected in healthcare such as reducing readmissions but focused on building up the framework of the National Strategy, such as focus on cross-care coordination, when possible, effectiveness of patient communication, timeliness of receiving care (Betancourt et al., 2017). Meanwhile, management is optimising processes, including standardising based on evidence or protocols. Strategic leadership also has to evaluate and consider human resources, training or hiring for various positions to meet certain performance criteria and organisational goals (Figueroa et al., 2019).

Guided by the Mental Health Strategy, the management team at Mount Carmel Hospital sought to bring a culture change to the whole organisation and reconfiguring the mental health services framework. The primary focus will be in improvement in patient care, which has been one of the main complaints in recent years from both patients and experts alike. The organisation will reorient towards a person-centred model of care. The staff and their dedication to provision of care is leading the cultural change, with an emphasis on building therapeutic relationships instead of the restrictive form of care practiced with mental health patients before (Azzopardi, 2021). Mount Carmel Hospital recruited professional experts to facilitate the organisational and cultural change. Training is one method that is being used to provide staff with skills and knowledge on how to better treat, interact, and respect mental health patients. The objective is to reinforce core values of Mount Carmel Hospital which was trust, integrity, and respect, while also adopting an outcome-focused perspective (Azzopardi, 2021). The patient-centred focus as well as a holistic approach to mental health provision will be the hospital’s strategic and cultural mantra going forward.

The culture present at Mount Carmel Hospital initially was counterproductive to the strategy framework being adopted. The culture was very conservative, deeply embedded into outdated policies and sometimes views of mental health. The focus of care was more on the process and protocols rather than building relationships with patients. Some questionable and potentially unethical practices were present such as tying down patients without necessity. It was and still partially is, a culture synonymous with the sociocultural perspective of the population as a whole, stigmatizing mental health and approaching patients as people that are ‘hopeless’ and unable to take care of themselves or their condition. This meant that adopting the framework undertook a change in perspective and understanding about mental health.

As mentioned previously, the organisation underwent a process of change under Kotter’s model, which greatly helped to implement some of the elements of the framework. However, the last step of ‘anchoring changes in corporate culture’ is perhaps the most challenging (Kotter, n.d.). An organisation’s culture is extremely complex, comprising of interweaving values, roles, processes, communications, and assumptions. Shifting a culture is long-term large-scale approach, because if only one aspect is changed, even if there is progress for a while, eventually the other elements will drag the stuts quo back down. An effective means to shift culture is through leadership that sets a vision, alongside management which produces tools to fulfil this vision with the help of staff. Finally, the last pockets of resistance to change can be coerced through power, but that should be rarely and carefully applied (Denning, 2011).

The Mental Health Strategy for Malta 2020-2030 is a comprehensive strategic document meant to guide development and governance of mental health services in the country as it grows from relative infancy to widespread community presence. This paper discussed the implementation of the National Strategy framework at the oldest and only in-patient psychiatric hospital in the country, Mount Carmel Hospital. Evaluating the implementation through the SWOT theoretical framework, it was generally a positive outcome for the facility. It required significant changes in its internal organisation, functions, and structure, but it provided a foundation of opportunities to grow in terms of service delivery and sustainability of the hospital.

Reference List

Azzopardi, K. (2021) ‘‘All complaints taken seriously, investigated’ – Mount Carmel Hospital CEO responds to criticism’, The Malta Independent.

Agius, M., Aquilina, F.F., Pace, C. & Grech, A. (2016) Stigma in Malta; A Mediterranean Perspective’, Psychiatria Danubina, 28(1), pp. 75-78.

Betancourt, J.R., Tan-McGrory, A., Kenst, K.S., Phan, T.H. and Lopez, L. (2017). Organizational change management for health equity: perspectives from the disparities leadership program. Health Affairs, 36(6), pp.1095–1101.

Calleja, C. (2021) ‘‘Infamous’ Mount Carmel must be tackled, say mental health professionals’, Times Malta.

Coughlan, C., Manek, N., Razak, Y. and Klaber, R.E. (2020). How to improve care across boundaries.BMJ, 369.

Denning, S. (2011) ‘How Do You Change an Organizational Culture?’, Forbes.

Figueroa, C.A., Harrison, R., Chauhan, A. and Meyer, L. (2019). Priorities and challenges for health leadership and workforce management globally: a rapid review. BMC Health Services Research, [online] 19(1).

Galea, S. and Mifsud, J. (2004) The mental health care system in Malta. International Psychiatry, 1(5), pp.11–13.

Grech, A. (2016). Epidemiology of Serious Mental Illness in Malta – Consequences for developing a new psychiatric hospital and community psychiatry.Psychiatria Danubina, [online] 28(Suppl-1), pp.108–110.

Kotter. (n.d.) The 8-step process for leading change.

Lia, E.S. (2017) A snapshot of psychology in Malta, the smallest country in the EU.

Office of the Deputy Prime Minister Ministry for Health. (2019) A mental health strategy for Malta 2020-2030.

Ogamba, I. and Nwaberiegwu, C. (2020) Persistent challenges to healthcare systems and the role of strategic and collective leadership. British Journal of Healthcare Management, 26(12), pp.1–5.

Pace, P. (n.d.) Mental health services, Malta.

Riwo-Abudho, Njanja & Ochieng, 2012) The role of strategic leadership during change. KCA Journal of Business Management, 4(2), 48(68).

Times of Malta. (2021) Mental Health in COVID times.

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Mount Carmel Mental Health Hospital’s Framework

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