2022 Public hospital report card - mental health edition

President's Introduction

prof stephen robson

Prof Stephen Robson

Federal AMA President

Australia’s health system is failing to provide appropriate, acceptable care to people experiencing poor mental health. This is painfully apparent in the growing numbers of patients presenting to public hospital emergency departments (EDs), often via ambulance, after they have exhausted all other avenues of seeking help they desperately need.

Attending an ED for a mental health issue may provide urgent care, but it is not the right setting to provide the longer-term whole-person care that is required for sustained recovery. The lack of mental health in-patient bed capacity caused by the public hospital logjam results in extended patient stays in EDs, causing distress for patients and their families.

The problem is a serious one that is frequently ignored which is why this year the AMA decided to develop a separate Edition to our Public Hospital Report Card that examines just one segment of public hospital performance – care for patients presenting for mental and behavioural disorders. Our aim is to shed the light on this often overlooked cohort, for whom our public hospitals frequently perform worse than for any other patient groups.

As this report card shows, from 1992 to 2020, Australia recorded a significant reduction in mental health beds, from 45.5 to 27.5 per 100,000 population - an almost 40 per cent decrease of available mental health public hospital beds. While this form of de-institutionalisation of mental health was needed and welcomed at the time, planning, funding or staffing for primary care or specialised community mental healthcare has been inadequate to meet the growing need.

Put another way, while the Australian population increased by 7,745,219, the number of public hospital mental health beds decreased by 587; a population increase by 43 per cent was met with a 7.7 per cent decrease in the overall number of mental health beds available.

The Mental Health Addendum also shows that the number of ED presentations per 10,000 population nationally almost doubled since 2004-05, from 69.2 to 120.6. Worryingly, with the increased number of presentations, the severity of illness of the mental health patients presenting is also increasing. The data show that a growing number of patients with mental health disorders are relying on ambulances when accessing EDs. In 2020-21, one in two patients (52.2 per cent) who presented to EDs for mental health disorders arrived via ambulance services. In contrast, less than one in three patients who present to EDs for all other conditions arrived by ambulance.

For patients presenting with mental and behavioural disorders that require hospital admission from the ED, the average wait times can range from 12 hours in Queensland to 28 hours in Tasmania. The national average wait time for the 90th percentile of patients presenting with mental health disorders is 19 hours and 29 minutes. That is almost an entire day of wait for a patient in distress, whose condition requires in hospital treatment.

These numbers point to a bed block, a lack of capacity in public hospitals to quickly and safely admit one in three patients who are, according to the data, on average, triaged for admission.

They are also unacceptable.

On becoming the AMA President, I made it clear that addressing the challenges to mental health care was one of my top priorities. In Australia we know that a certain proportion of the population will suffer from severe mental health illnesses that will require hospitalisation. We also know that suicide is the leading cause of death among people aged 15 to 44 in Australia. We rank above the Organisation for Economic Co-operation and Development (OECD) average in the number of deaths by suicide. We need to improve these figures.

In 2015 we were told by OECD that “without sufficient high-quality community care, and with low inpatient psychiatric bed numbers, patients with severe mental illness risk worsening symptoms, more stays in emergency settings, and more hospital readmissions. Australia should pay attention to getting the tricky balance of care provision right.” Seven years on, it seems we have failed to heed this warning.

As a result, ED clinical staff are under increasing pressure, leading to stress, burnout and emergence of their own mental health issues. More recently, we have seen calls for deployment of police officers in EDs and employment of security guards to protect the staff from aggressive patients who become agitated by waiting long hours.

Our patients know this from first-hand experience. They know the anguish of spending 28 hours in an ED, waiting for a bed, so that they can be safely admitted and receive adequate care. Not having the opportunity to have comprehensive and adequate duration of inpatient care due to lack of beds and staffing. Being sent home from ED to go and see a GP for a referral to a psychiatrist as an outpatient, only to learn that there aren’t any available.

Parents and relatives sadly know the heartache of battling though the system for years and all too often they still end up losing their loved ones to suicide.

We can and should be doing more to fix these systematic issues.

We need to start by addressing the lack of funding, beds, infrastructure and lack of staff. Politicians will always find more important things to fund than healthcare, or they will simply provide grants to siloed services that do not address systematic issues to signal they are doing something, instead of fixing Medicare and the public hospital system.

Australian patients need a better, longer-term solution. The AMA is calling for the modernisation of Medicare to support GP-led collaborative Primary Care, increasing the number of mental health beds in public hospitals to avoid the Logjam that particularly disadvantages mental health patients, and we need to increase mental health community service staffing and resources. We urgently need to increase our mental health workforce numbers so we have the right workforce of GPs, psychiatrists, nursing and allied health professionals to wrap care to support patients throughout their illness to recovery.

Ultimately, if we want to ‘get the tricky balance of care provision right’, the future policy around improving mental health care must be guided by the Mental Health professional community. Funding and strategies to address the mental health crisis in Australia’s hospitals must include public hospital doctors in the discussion. It must also include GPs, psychiatrists and other mental health professionals who are all part of the same disjointed, underfunded system struggling to manage mental ill health in the community.

While this paper focuses solely on mental health in public hospitals, we know that mental health led by GPs in primary care must also be improved with adequate resourcing, with the support for our psychiatrist workforce in public and private sectors. We need to move towards a functioning mental healthcare system. Let’s start by fixing our public hospitals.

Introduction – The Mental Health Problem

According to an Australian Bureau of Statistics (ABS) 2020-21 survey, mental and behavioural conditions were the most prevalent chronic conditions in Australia, with one in five people (20.1 per cent) experiencing some form of poor mental health.1 The numbers are even higher for young people, particularly young females, where almost one in three girls aged 15 to 24 will be affected by mental and behavioural conditions, the most common ones being anxiety and depression.2

Furthermore, the ABS survey statistics from 2001 onwards show a constant growth in self-reported poor mental health. In 2001, 9.6 per cent of the population reported mental and behavioural disorders. That proportion grew to 17.4 per cent in 2014–15,3 only to almost double by 2020 21 (20.1 per cent).

Suicide is the leading cause of death among the 15 to 44 age cohorts in Australia.4 Australia ranks above the Organisation for Economic Co-operation and Development (OECD) average in the number of deaths by suicide (OECD average is 11, Australia stands at 12.3 suicides per 100.000 population).5 Although the causes of suicide are often complex, in a majority of cases they can be linked to mental illness, with depression, substance use disorders and psychosis being the most relevant risk factors.6

Yet the Australian health system seems to be ill equipped to provide support to patients presenting with poor mental health. This is evident by the growing numbers of patients presenting to public hospital emergency departments (EDs), often the last resort for patients in distress who have exhausted all other avenues of seeking help, even when both clinical staff and patients know that EDs are not suitable spaces for mental health patients.7

Mostproblems in the public hospital system happen at intersections of federal and state/territory funding areas. Obvious examples include aged care and disability, where over the past decade there has been a growing reliance on public hospitals to pick up patients and provide care for patients who are not able to receive the care they need under the aged care and National Disability Insurance Scheme (NDIS) systems.

The AMA argues that mental health care is one of those intersections. The Australian Government fully funds aged care and disability services and has had a growing role in funding and managing mental health care, particularly mental health care in the community, both through Medical Benefit Schedule (MBS) funding (by subsidising general practice, specialist psychiatry or psychology) and Pharmaceutical Benefits Scheme (PBS), but also through increasingly providing funding to non-governmental organisations (NGOs) and providers such as headspace to provide early intervention and prevention.

The Better Access Initiative was established by the Australian Government in 2006 with the aim of improving “access to, and better teamwork between, psychiatrists, clinical psychologists and other allied health professionals”8 and to “improve outcomes for people with a clinically-diagnosed mental disorder through evidence-based treatment”. 9

Under the initiative, Medicare rebates are available for general practitioners (GPs) to provide early intervention, assessment and referral of patients with mental disorders as part of a GP Mental Health Treatment Plan. GPs can refer patients for Medicare rebated psychological services to psychiatrists, psychologists (psychological therapies), appropriately trained mental health social workers and occupational therapists (Focussed Psychological Strategies [FPS]), as well as GPs who are registered providers of FPS). For example, patients can receive up to 20 Medicare-rebated sessions with a psychologist per year, once they have consulted and created a mental health plan with their GP.

The data shows that in 2016 (last Bettering the Evaluation and Care of Health [BEACH] survey) 12.4 per cent of all GP encounters with patients were for management of psychological problems.10 That means that 6 years ago one in eight patients seen by GPs needed to access mental health supports. According to the RACGP’s last Health of the Nation Report 2021, mental health was the most commonly reported reason for patient presentations in general practice, with 71 per cent of GPs selecting ‘psychological’ in their top three reasons for patient presentations.11

Even with the growing uptake of the Better Access Initiative since its establishment,stakeholders have raised issues with the initiative, the most obvious one being the lowering of bulk billing rates and growing out-of-pocket costs due to inadequate indexation of MBS rebates over the years. But despite this, the Better Access Initiative remains the one initiative where continuity of care and care coordination in mental health care is provided through the patients’ existing relationships with GPs and the development of a mental health plan.

Furthermore, Medicare funded mental health services, even with their increased uptake, cost less than other government funded services. According to Australian Institute of Health and Welfare (AIHW), $1.4 billion, or $53 per Australian, was spent by the Australian Government on benefits for Medicare-subsidised mental health-specific services in 2019–20. By comparison, per capita cost (constant prices) of units and wards in specialist psychiatric units of public hospitals was $90.11, while $100.49 per capita was spent on community mental health services.12

Additionally, in 2019–20, the Australian Government spent $63.82 per capita (constant prices) on ‘National Programs and Initiatives’, that includes programs managed by the Australian Government Department of Health and Aged Care; Department of Social Services; Department of Veterans Affairs; Department of Defence; Indigenous social and emotional wellbeing programs and the National Suicide Prevention Program13

Headspace is one of the programs funded under National Programs and Initiatives.14 Headspace provides services to young people between 12-25 years, to improve their health and wellbeing, including mental health and wellbeing, physical and sexual health, work and study support, and alcohol and other drug services.15

Based on the review of Australian Budget papers, the AMA estimates that Headspace has received around $600 million in funding since 2019 from the Australian Government.16 In addition to the (grant) funding by the Australian Government, additional funding may be provided by PHNs, state governments to deliver core services and through MBS activity-based funding of services. Headspace also receives in-kind contributions, private donations, and can charge out-of-pocket payments from young people or their carers.17

An evaluation commissioned by the Department of Health and Aged Care published in October 2022 found that “no single source captures these ranges of costs of delivering headspace”.18 The evaluation concluded that the longer-term impacts of headspace are not measured and that improvement in data collection is required. It recommends that the linked data sets include:

  • self-harm hospitalisations
  • substance abuse hospitalisations
  • suicide deaths
  • MBS mental health services accessed
  • PBS usage
  • mental health related emergency department presentations
  • education and employment outcomes
  • income support use.19

The Productivity Commission’s report into Mental Health Services suggested that “funding to headspace should not be hypothecated. Rather, like any commissioned service, headspace should be required to show how its services are meeting local needs in order to receive ongoing funding”.20

Where does this leave people who need mental health care?

Gaps remain in access to primary and community care (aged care, NDIS), which need to be filled by Modernising Medicare21 to facilitate joined-up care led by GPs. In addition, we have a limited understanding about how federally funded national programs and initiatives like headspace influence tertiary care and hospitalisations. Immediate progress on the above listed data linkages recommended by the headspace evaluation would hopefully help better inform health policy and better target funding to the areas of need.

The shortfalls in primary care, due to the lack of fit-for-purpose general practice Medicare-reimbursed models of care, means patients increasingly rely on EDs and hospitals. And while this reliance may provide an immediate, short-term reprieve, EDs are not appropriate environments for mental health patients.22 Furthermore, lack of in-patient bed capacity in public hospitals results in extended patient stays in EDs, exacerbating the problem.

Staff working in EDs are focused on managing mental health crises and associated medical needs. They are not trained nor resourced to manage patients with complex mental health issues, who can become agitated and aggressive (especially when facing long waits for care) and this can lead to assaults on staff.

Similarly, the physical design of public hospital EDs is often not conducive to quality mental health care. Because of all of this, ED clinical staff are under increasing pressure, leading to stress, burnout and emergence of their own mental health issues. More recently, we have seen calls for establishment of security services in EDs and employment of security guards to protect the staff from aggressive patients who become agitated by waiting long hours.23

Finally, the long term impact of COVID-19 on the mental health of the population is yet to be seen. According to the data available to the AIHW, the COVID-19 pandemic did not impact the rise in suspected deaths by suicide in 2020 and 2021.24 However, we know the pandemic placed an extraordinary strain on primary care and acute hospital and community care that was already faltering under pre-existing demand.

The prolonged nature of the pandemic has led to workforce impacts including burnout and mental illness that has created a further cycle of decline of staffing levels as doctors and other health professionals exiting the sector.25

Australian patients need a better and longer-term solution. Based on AMA analysis, that solution must include the modernising Medicare to support GP-led collaborative Primary Care and an increase in public hospital and community service capacity — primarily the number of mental health beds in public hospitals to avoid the hospital logjam that particularly disadvantages patients with mental illness. Furthermore, future policy on improving mental health care must be guided by the mental health professional community.

National Public Hospital Mental Health Performance

In 2019-20 total of 161 public hospitals provided specialised mental health services for admitted patients, including 144 public acute hospitals with a specialised psychiatric unit ward and 17 public psychiatric hospitals

View national stats
mental health report card

State by state public hospital performance

View the performance of each state


1ABS 2022. Health Conditions prevalence. Key findings on selected long-term health conditions and prevalence in Australia - Reference period 2020-21. https://www.abs.gov.au/statistics/health/health-conditions-and-risks/health-conditions-prevalence/latest-release


3ABS 2015. National Health Survey: First Results 2014-15. Table 1: Summary of Health Characteristics, 2001-2015-15 – Australia. https://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4364.0.55.0012014-15?OpenDocument

4AIHW 2022. Life expectancy and deaths. Deaths in Australia https://www.aihw.gov.au/reports/life-expectancy-death/deaths-in-australia/contents/leading-causes-of-death

5OECD 2021. "Mental health", in Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/f9c64182-en

6Bachmann S. Epidemiology of Suicide and the Psychiatric Perspective. Int. J. Environ. Res. Public Health. 2018;15:1425. doi: 10.3390/ijerph15071425 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6068947/

7Suicide Prevention Australia 2022. In Their Words: How to support young people in suicidal distress https://www.suicidepreventionaust.org/wp-content/uploads/2022/08/SPA_Youth-Report_In-your-words_12-August-2022.pdf

8COAG, National Action Plan on Mental Health 2006–2011, p. i.

9RACGP, Better Access Initiative https://www.racgp.org.au/education/gps/managing-mental-health/better-access-initiative

10Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L, Pan Y, Charles J, Pollack AJ, Wong C, Gordon J. General practice activity in Australia 2015–16. General practice series no. 40. Sydney: Sydney University Press, 2016. Available at purl.library.usyd.edu.au/sup/9781743325131 P.19

11RACGP, General Practice Health of the Nation 2021. Chapter 1: Current and emerging issues 1.1 Common health presentations in general practice https://www.racgp.org.au/health-of-the-nation/chapter-1-current-and-emerging-issues/1-1-common-health-presentations-in-general-practice

12AIHW 2022. Mental Health Services in Australia. Expenditure on Mental Health Services https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-content/expenditure-on-mental-health-related-services


14Australian Government, The Department of Health and Aged Care 2022. Programs & Initiatives – Results. Topic: Mental Health https://www1.health.gov.au/internet/main/publishing.nsf/Content/programs-initiatives-results?OpenDocument&KEYWORD=&TOPIC=Mental+health&SUBMIT=Topic+search,Topic+search

15Headspace. How headspace can help. https://headspace.org.au/explore-topics/for-young-people/headspace-can-help/#:~:text=What%20can%20headspace%20help%20with,alcohol%20and%20other%20drug%20services

16Commonwealth of Australia 2019. Budget Measures Budget Paper No 2 2019-20: https://archive.budget.gov.au/2019-20/bp2/download/bp2.pdf

  • The Government will provide $263.3 million over seven years from 2018-19 (including $109.9 million beyond 2022-23) to improve access to youth mental health services across the national headspace network, including:
    • $152.0 million for additional services across the headspace network to reduce waiting times for young people seeking mental health services; and
    • $111.3 million for an additional 30 headspace services, including satellite services in Sarina and Whitsunday, Queensland. This will expand the headspace network to 145 services across Australia by 2021.
  • Commonwealth of Australia 2020. Budget Measures Budget Paper No 2 2020-21: https://archive.budget.gov.au/2020-21/bp2/download/bp2_complete.pdf
    • $5.0 million in 2020-21 for headspace to increase outreach services to young people in the community who are in severe distress
    • $2.3 million over four years from 2020-21 to enhance the National headspace network by upgrading the Mount Barker service in South Australia to a full centre (This measure builds on the July 2020 Economic and Fiscal Update measure titled Prioritising Mental Health and Preventive Health — continued support and the 2019-20 Budget measure titled Prioritising Mental Health — national headspace network.)
    • $18.9 million over five years from 2019-20 to enhance the National headspace Network by upgrading Batemans Bay (New South Wales), Roma and Emerald (Queensland) to full centres, commencing early service delivery in Rosebud and Pakenham (Victoria), establishing an outpost service in Hastings (Victoria), continuing the headspace Schools Suicide Prevention Activities for a further two years from 2020-21, and to conduct an independent evaluation of the Network
  • Commonwealth of Australia 2021. Budget Measures Budget Paper No 2 2021-22: https://archive.budget.gov.au/2021-22/bp2/download/bp2_2021-22.pdf
    • $278.6 million over four years from 2021-22 to expand and enhance headspace youth mental health services, including in conjunction with the states and territories
  • Commonwealth of Australia 2022. Budget Measures Budget Paper No 2 2022-23: https://budget.gov.au/2022-23/content/bp2/download/bp2_2022-23.pdf
    • $14.8 million over 5 years from 2021-22 to continue a range of headspace programs including flying headspace, the Digital Work and Study Service, and schools suicide prevention activities
    • $4.2 million over 5 years from 2021-22 to support employment of general practitioners in headspace centres in rural and remote regions

17KPMG 2022. Evaluation of the National headspace Program – Final Report https://www.health.gov.au/sites/default/files/documents/2022/10/evaluation-of-the-national-headspace-program.pdf



20Productivity Commission 2020. Report into Mental Health Services. Funding and commissioning arrangements. Page 115 https://www.pc.gov.au/inquiries/completed/mental-health/report/mental-health.pdf

21AMA 2022. AMA’s plan to Modernise Medicare https://www.ama.com.au/modernise-medicare/our-plan

22Suicide Prevention Australia 2022. In Their Words: How to support young people in suicidal distress https://www.suicidepreventionaust.org/wp-content/uploads/2022/08/SPA_Youth-Report_In-your-words_12-August-2022.pdf

23Australian College of Emergency Medicine. ACEM calls for 24-hour security guard in every Victorian ED. Media Release 10 September 2022 https://acem.org.au/News/September-2022/ACEM-calls-for-24-hour-security-guard-in-every-Vic?fbclid=IwAR3Iez1m-lsAVq8aNzx9_DN9Ba3Zu63-wRWWOOD8FWR-8gSdoLLKnj-Bdv4

24AIHW 2022. Suicide and self-harm monitoring data. The use of mental health services, psychological distress, loneliness, suicide, ambulance attendances and COVID-19 https://www.aihw.gov.au/suicide-self-harm-monitoring/data/covid-19

25Looi JC, Allison S, Bastiampillai T, Brazel M, Kisely SR, Maguire PA. Psychiatrist and trainee burnout: Commentary and recommendations on management. Australasian Psychiatry. 2022;0(0). doi:10.1177/10398562221124798