National public hospital mental health performance

National public hospital mental health capacity

The above graph shows the decline in the number of hospital mental health beds over the last 30 years. The start of the decline can be linked to the establishment of a National Mental Health Strategy and the first five-year National Mental Health Plan in 1992, which focused on expanding community mental health services and reducing the reliance on stand-alone psychiatric hospitals, by increasing links between mental health care and general health care and linking mental health activities with other sectors.²⁹ The decline in numbers can mostly be attributed to the closure of specialised mental health hospitals or, in states where they were not closed, the reduction in their capacity. While this type of deinstitutionalisation of mental health care was needed at the time, the outcomes have not met the expectations.

While the number of hospital beds decreased by 587, the Australian population increased by 7,745,219 in the same period.³⁰ A population increase by 43 per cent was met with a 7.7 per cent decrease in the number of beds.

Measured by 100.000 population, in 2019-20 Australia had 27.5 mental health care public hospital beds per 100.000 people, while in 1993-94 that number was 45.5.³¹

In 2015, in light of the declining public hospital mental health capacity, the OECD warned Australia to ensure that that needs were still being met.³² At the time Australia had 39 mental health beds per 100,000 population.

Although the number of hospital beds is not necessarily an indication of the quality of mental healthcare provided, it is an indicator of the capacity of the system to provide acute care for those patients who need it. Italy for example has one of the lowest numbers of public hospital psychiatric beds in the OECD, yet it is considered a leader in moving the mental health care from institutions to community for people with severe mental health illness.³³

However, a certain percentage of the population will suffer from severe mental health illness that will require hospitalisation, and the system capacity must be there to meet this demand. Or as the OECD put it: “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.”³⁴

Despite national mental health reviews and plans over the past 20 years focusing on prevention and early intervention³⁵, investment in mental health services has failed to address gaps in service access and availability to meet the ongoing need, resulting in many Australians turning up to emergency departments in public hospitals.³⁶

Emergency department presentations

The available data points to an increase in numbers of the Emergency Department presentations nationally over the years. As the graph below shows, the number of ED presentations per 10,000 population nationally almost doubled since 2004-05, from 69.2 to 120.6 per 10,000 population.

Worryingly, the data shows, that along with the increased number of presentations, the severity of illness of the mental health patients presenting seems to be increasing. Specifically, since 2004, the number of patients presenting at EDs who are triaged as resuscitation³⁷ has grown from 0.6 per 10,000 population in 2003-04 to 1.7 in 2020-21. That is a 12.3 per cent average annual increase over the five years since 2016-17.³⁸

Similarly, the number of mental health patients triaged as Category 2 - Emergency (to be seen within 15 minutes) and Category 3 – Urgent (to be seen within 30 minutes) has been increasing, by 8.0 per cent and 3.3 per cent per 10,000 population, respectively, in the same period.³⁹

Mental health emergency department waiting and treatment times – mental health

Time spent in EDs for mental health presentations ending in admission

When mental health patients present at emergency departments, unless triaged as resuscitation, they tend to wait longer to be treated than patients triaged in the same categories for other conditions. In 2020-21, more than one in three patients, or 35.9 per cent, presenting at emergency departments for mental and behavioural disorders were admitted to hospital.

As an illustration, 90th percentile length of emergency department stay for all emergencydepartment presentations ending in admission in 2020-21 was 12 hours 57 minutes, ranging from 10 hours in Queensland to 22 hours in Tasmania.⁴⁰

However, for patients presenting with mental and behavioural disorders that require admission from ED, the 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 disorders is 19 hours and 29 minutes.⁴¹ That is around 7.5 hours longer than average for all ED presentation and almost an entire day of wait for a patient in distress, whose condition requires in hospital treatment.

These numbers point to a bed block, lack of capacity in public hospitals to quickly and safely admit patients who are triaged for admission.

As shown previously, patients presenting with mental and behavioural disorders tend to wait longer to receive treatment in emergency departments. The data shows that 63.8 per cent of mental health-related ED presentations were seen on time in 2020-21, 7.2 per cent below the average for all ED presentations (71 per cent).⁴²

Because this report card uses the AIHW published data, it is important to note that according to the AIHW definition of data sources and key concepts, mental and behavioural disorders principal diagnosis codes may not fully capture all mental health-related presentations to EDs, such as presentations for self-harm. Diagnosis codes for intentional self-harm sit outside the Mental and behavioural disorders chapter.⁴³

Emergency department mental health presentations ending in admissions

Since 2013-14, there has been a steady increase in patients with mental and behavioural disorders presenting at emergency departments who are subsequently admitted to hospital.

The above graph shows a steep decline in ED mental health presentations ending in admissions between 2011-12 and 2013-14. It was in In February 2011 the Council of Australian Governments (COAG) agreed to reform of the mental health system as part of broader National Health Reform, committing $2.2 billion over five years in the 2011-12 Budget to National Mental Health Reform “to help Australians who have a mental illness get the care they need, when and where they need it”.⁴⁴

Emergency Department presentations – ambulance arrival

The data available through AIHW shows that growing number of patients with mental health disorders are relying on ambulances (including air ambulance or helicopter rescue service) when accessing emergency departments. In 2020-21, one in two patients (52.2 per cent) who presented to EDs for mental health disorders arrived at EDs via ambulance services. In contrast, less than one in three patients overall who present to emergency departments arrive by ambulance. Furthermore, the numbers of mental health ED presentations with ambulance as arrival mode has been growing by 3.9 per cent year on year since 2016-17.⁴⁵

The percentage growth differs between states and territories, but is evident that in some states, like Queensland for example, mental health patients increasingly depend on ambulances to transfer them to emergency departments. This can be a sign of growing acuity of mental health disorders in patients and/or lack of access and availability of care in the community, lack of access to GPs, psychiatrists and psychologists and other types of community care. More data on individual states and territories is provided in subsequent chapters.

Overnight admitted mental health care

The overnight admitted mental health related data portrays a grim picture of the public hospital patients being admitted for mental and behavioural disorders.

Similar to the Emergency Department presentations, the number of overnight admitted mental health patients in public hospitals has been growing, with an average annual increase of 3.6 per cent since 2009-10 to 2019-20.⁴⁶ And while total number of non-mental health hospitalisations in the public system in 2019-20 (Covid-19 impacted year) reduced by 3.7 per cent compared to the previous year, the number of mental health hospitalisations increased by 1.8 per cent on the previous year.

Three parameters of mental health hospitalisations, all point to an increase in the overall share of hospitalisations: proportion of overall hospitalisations, proportion of patient days taken up by mental health patients and proportion of mental health related procedures.⁴⁷

Noting that length of stay for mental health patients is generally not comparable with the length of stay of all other types of patients, due to the complexity of the medical condition and the needs of admitted mental health patients, we use it in this report to illustrate the bed block and the need for increased capacity. Specifically, once admitted, mental health patients optimal length of stay is 14-21 days. In 2019-20, the average length of stay for mental health patients in public hospitals was 13.1 days, while for all other patients it was 4.9 days.⁴⁸

Average length of stay in public acute hospitals with specialist psychiatric care in 2019-20 ranged from 18.1 days in New South Wales to 11.9 days in Northern Territory.

For mental health patients to be discharged from hospital into the community adequate supports and transition of care are needed.

Australian Government funding – mental health public hospitals

Despite the growth in the national population and the reduction in reliance on public acute specialised hospitals for care of mental health patients, from 1992-1993 to 2019-20, the Government mental health-related expenditure as a proportion (per cent) of Government health expenditure grew only by 0.32 per cent (from 7.25 per cent in 1992-93 to 7.57 per cent in 2019-20).⁴⁹

As explained previously, the Federal expenditure is mostly directed towards MBS, PBS and ‘National Programs and Initiatives’, while the state/territory expenditure goes towards the acute care in public hospitals and mental health care in the community.