This audit assessed whether people can access adult State-managed mental health services efficiently and effectively.
We looked at whether mental health services are managed to deliver the Better Choices. Better Lives: Western Australian Mental Health, Alcohol and Other Drug Services Plan 2015-2025. We analysed the way people accessed mental health care in hospitals, emergency departments and community mental health teams from 2013 to 2017.
The audit covered the activities of the following State government entities (entities): Mental Health Commission (MHC), the Department of Health (the Department) and Health Service Providers (HSPs): North Metropolitan Heath Service (NMHS), South Metropolitan Health Service (SMHS), East Metropolitan Health Service (EMHS) and the Western Australian Country Health Service (WACHS). The Department and the HSPs together are known as WA Health.
Mental health issues range from severe and persistent mental distress to mild and occasional incidents. Severe mental illness can be debilitating, and can require ongoing care and support. It often increases a person’s vulnerability to homelessness, unemployment, poverty, discrimination and isolation. Lower levels of distress can range from people needing to seek their own intensive treatment with a clinician to needing low intensity care every so often.
In 2017-18 the National Health Survey found that around 1 in 5 Australians, or 4.8 million people, had a mental health or behavioural condition that year. This had risen from 4 million people in 2014-15. Almost half of the population experience a mental health disorder at some point in their life. Anxiety and affective disorders like depression are the most common mental health disorders.
Efficient and effective mental health services should help people stay in the least intensive care possible to manage their condition and then provide accessible pathways to more intensive care when they need it. This approach is beneficial for people who seek care, and is also more cost effective.
The delivery of mental health care in Western Australia is complex. It involves Commonwealth and State government effort as well as individually-funded services, from general practitioners to hospital care and private professional care.
The MHC funds 5 key mental health service streams:
- prevention, which includes suicide prevention projects and public awareness campaigns
- community support services, which includes hostels and recovery colleges
- community bed-based services, including step-up/step-down services
- community treatment services, which mainly consist of community mental health teams managed by HSPs
- hospital bed-based services, which are dedicated mental health units in hospitals provided by HSPs.
At present, the key document that guides the strategic direction of mental health services is the MHC’s Better Choices. Better Lives: Western Australian Mental Health, Alcohol and Other Drug Services Plan 2015-2025.
Better Choices. Better Lives: Western Australian Mental Health, Alcohol and Other Drug Services Plan 2015-2025
In 2015, the MHC published the Better Choices. Better Lives: Western Australian Mental Health, Alcohol and Other Drug Services Plan 2015-2025 (the Plan). This document describes an increased range of services to improve the accessibility and availability of services for people with severe mental health issues. A central goal was to build a system of person-centred care. The Plan articulates a future state of mental health care and notes that many of the initiatives will require significant investment. The Plan was not funded, and notes that investment would be ‘dependent on Government’s fiscal capacity’ and ‘subject to Government approval through normal budgetary processes’.
The Plan compared the volume of services available in 2012-13 and 2014 to those needed to meet demand. It showed that services fell short of optimal levels, providing:
- 20% of community support services needed
- 71% of community treatment services needed
- 40% of community bed-based services needed
- 74% of hospital bed-based services needed.
To achieve optimal levels, the Plan outlined changes to how expenditure should be proportioned, but not the total amount of investment required. Figure 1 shows the pre-Plan and 2025 target funding proportions.
In the Plan, 2017 and 2020 were set as intermediate timelines to measure progress in achieving the optimal mental health service mix. The first phase was primarily for planning to prepare for the future. The period from 2017 to 2020 was when the system should be rebalanced. The Plan stated that the first priority should be to boost investment in community-based services.
Community and hospital based mental health care
State-managed care options are intended to focus on people with severe mental health issues. The State’s mental health services fall into two broad areas, community services and hospital services. Across WA, 18 hospitals provide around 740 dedicated mental health beds, excluding the State Forensic Centre. A third of the beds are ‘secure’ and intended for those at risk of physical harm to themselves or others.
Community services consist of community treatment, community support and community bed-based services. Community treatment services are largely clinical services provided by community mental health teams managed by the HSPs.
Community support services include those that the MHC has directly contracted from non-government organisations (NGOs). These are non-clinical support services such as personalised support programs, peer support, family and carer support.
Community bed-based services include short, medium and long stay accommodation provided by non-government organisations and include step-up/step-down facilities. Step-up/step-down facilities support people following discharge from a hospital, or those in the community experiencing a change in their mental health, to avoid the need for a possible hospitalisation. Non-government organisations offer a range of residential mental health services covering accommodation, respite, crisis and transition care.
The State also provides mental health services through hospital emergency departments (EDs). These are funded through individual HSPs, not the MHC, and the total cost of providing mental health care in EDs is not known. The MHC funds Mental Health Observation Areas that operate alongside EDs in 2 hospitals.
Management of the mental health system
The Department and the MHC are the two key administrators of public mental health services in WA. The MHC is responsible for mental health planning and strategy, setting the range of services needed, and for specifying, monitoring and evaluating service levels. It is also responsible for purchasing specialised hospital and community mental health services. Hospital services are purchased from the HSPs and community services from both HSPs and non-government organisations.
The Department provides strategic leadership and oversight, policy setting and planning for the entire WA health system. It oversees and monitors mental health services as part of this function. It sets directions for HSPs through formal agreements, and supports operational HSPs, which are individually accountable authorities for the region and services they provide, including mental health.
The HSPs are legally responsible and accountable for mental health services provided by hospitals and community treatment services under their control:
- there are 3 HSPs in the Perth metropolitan area (North, South and East)
- WA Country Health Service is the HSP for regional WA
- the Child and Adolescent Health Service is the HSP for child and adolescent health across the State.
Our audit focused on access to adult mental health services so we excluded the service policies and processes specific to children and adolescents provided by the Child and Adolescent Health Service.
Primary health care providers and private clinical mental health providers also deliver mental health care. These include general practitioners and private clinics, hospitals, psychiatrists and psychologists. This care is not funded or managed by entities, and was therefore not included in our audit.
An efficient and effective State-funded mental health care system should help people to stay in the least intensive care setting required to manage their condition, while providing access to more intensive care when needed. The Better Choices. Better Lives: Western Australian Mental Health, Alcohol and Other Drug Services Plan identified an urgent need to expand community mental health services and rely less on costly hospital beds. It is a soundly devised plan, developed with extensive consultation and strong support from consumers and care providers. However, there has been limited progress in implementing the Plan to rebalance the service mix. This means that the system continues to deliver services inefficiently and ineffectively. The Plan aimed to reduce the proportion of funding for hospital beds from 42% to 29% by 2025. By the end of 2017-18, it had instead risen to 47% of State mental health funding.
The MHC has not developed a system-wide implementation plan to support the Plan, and the lack of an agreed funding strategy means implementation has relied on ad-hoc investment. There has also been a lack of clarity around who is responsible for managing mental health care, which has worked against effective coordination between the entities. These factors have slowed progress in changing the mix of mental health services to better match needs. For some people this means there are gaps in services, so they continue to rely on acute, higher cost and often less suitable care settings. People accessing community treatment services in 2017 were receiving less care on average than in 2013.
The MHC and WA Health’s understanding of how people use mental health services relies on activity data and lived experience but does not identify the patterns of people accessing care. Our data analysis created a system-wide view of how people have used services over time and shows how 4.8 million care events were delivered to more than 212,000 people between 2013 and 2017. Just 10% of these people used 90% of hospital care and almost 50% of emergency and community treatment services. Without systematically examining people’s pathways in combination with existing information on lived experience, the MHC cannot develop, prioritise and cost appropriate solutions to provide mental health care efficiently for key groups of vulnerable people.
There has been limited progress implementing the Plan since it was released in 2015
The MHC’s Plan provided a soundly devised and widely accepted picture of the mix of the mental health services needed to meet people’s needs by the end of 2025. It focused on quantifying gaps in services using nationally agreed, evidence-based, modelling tools. The development of the Plan involved an extensive consultation process. The MHC was responsible for ensuring that the Plan was accepted as a blueprint for the future of mental health services and delivered in partnership with many key stakeholders.
However, since the Plan was launched in 2015 there has been little progress in changing the mix of mental health services. The MHC has not yet made progress in rebalancing investment to move away from investing in more high-cost acute hospital-based services. Against the Plan’s baseline proportional spend, the funding for hospital beds has increased from 42% to 47%. The proportion of funding on community treatment services has remained the same at 43% and the proportion of funding on prevention and community support has both decreased (3% to 1% and 8% to 5% respectively). The MHC’s 2019 progress report notes that it had only finalised 24% of projects it expected to complete by 2017, with a further 67% in progress.
A number of factors have contributed to the limited progress. Although the MHC has developed a number of strategies for engagement and service design, it has not yet developed a system-wide implementation plan or funding strategy that would support a coordinated approach by all entities. This has led to ad-hoc changes to services, with limited progress in overall mental health service reform.
Without an agreed funding strategy, it remains unclear how the additional investment in infrastructure and services needed to move to the optimal service mix will be funded, while ensuring that existing services continue. This makes it difficult for the MHC to demonstrate how the optimum service mix in the Plan will be achieved by the end of 2025.
It is also not clear if either the MHC or the Department is responsible for delivering the necessary changes to the mix of mental health services to ensure care is efficient and effective. The HSPs deliver the vast majority of the services and follow direction from both MHC and the Department. To effectively implement the changes in service mix under the Plan, the HSPs need clear, coordinated direction from the MHC and the Department.
The MHC has implemented some initiatives from the Plan, including 3 step-up/step-down (SUSD) facilities and funded a Hospital in the Home (HITH) service. Consumers and providers of these services are reporting benefits and indicate that they fill some of the gaps in service mix for some people. However, implementing these services has also highlighted the remaining unmet need for services. HSPs reported to us that the eligibility criteria in step-up/step-down facilities can be restrictive. HSPs also indicated that they were unable to refer some people with more severe issues stepping down from hospital to the service. They reported it does not provide enough clinical contact. Similarly, the North Metropolitan Health Service reported that eligibility criteria could limit the number of people who could access the HITH service and we noted that occupancy rates were below target occupancy.
The current mix of mental health services has not changed significantly and does not work as intended for some people
The current service mix is struggling to meet the need for people to have access to appropriate services when they need them. The mix has changed little over the period of our analysis, and it continues to result in people being cared for in the most intensive and higher cost care settings, which is both an inefficient and often less effective way to provide care.
Our analysis of people’s pathways highlighted a number of areas where mental health hospital services were not used as intended:
- Acute mental health hospital beds are intended to provide short term, stabilising care to people in crisis or with acute mental health needs. The target for the average length of stay in acute mental health beds is less than 15 days. Each acute bed costs the MHC $1,500 a day. During 2013 to 2017, we found that 126 people spent more than 365 consecutive days in an acute hospital bed. The hospital fees alone for these providers during this period cost the public system an estimated $115 million. Another 158 people had multiple stays in acute beds that totalled 365 days or more across the same period. These long stays mean that hospitals must operate with less capacity for people who also need urgent access to care, reducing the availability of services overall. They are also the most expensive care option, and WA Health cannot systematically demonstrate they are the most cost-effective care option for this cohort.
- EDs are being used as a gateway, and hospital care has become harder to access with people spending more time in ED in order to access a secure mental health bed. From 2013 to 2017, almost half the people seeking care first accessed State-funded mental health services through an ED. Over the same period, we found 2,278 people had 3 or more ED visits in the 7 days before they were admitted to hospital for mental health care. This suggests community pathways to hospitals are not working for a significant number of patients.
- People seeking mental health care also spend longer in ED. In 2017, the average length of time all people who presented spent in an ED was 3 hours. This figure was doubled for mental health patients, in turn increasing the pressure in EDs.
To reduce the reliance on more intensive and higher cost hospital care, the Plan intended to increase access to a greater range of community services. From 2013 to 2017, there was a 17% increase in the number of people accessing community treatment services, but there was no increase in the total hours of care delivered. As a result, the people who accessed community treatment services received less care on average.
MHC and WA Health do not use existing data effectively to manage service delivery and reform
The MHC and WA Health’s capacity to improve the mix of mental health services is limited by how they use the existing data. For example, the MHC and WA Health know the volume of care provided, but do not know how many people accessed care or if they are using services as they were intended. This is because the current measures track the numbers of times a service is delivered rather than who used the service. If the MHC and WA Health used existing data in new ways to understand more about how people interact with existing services, they could develop targeted, more cost effective care options. In turn, it would allow the MHC and WA Health to justify and prioritise the changes to the service mix that were in the Plan. Using the existing data alongside the information the MHC collects on people’s lived experience could further develop person-centred care at a system-wide level.
Focusing on each discrete activity in the mental health system, rather than how people use services, means the MHC lacks some of the information needed to effectively quantify demand, prioritise investment and demonstrate its expected benefits. We undertook a data analytics exercise that linked instances of care from in-patient, ED and community treatment services to create episodes of care for people. These episodes allowed us to follow people’s pathways across State mental health services over time and we found that more than 212,000 people accessed State-managed mental health care from 2013 to 2017. While 30% of these people only accessed State-managed care once, 10% (21,000) used services much more intensively. This 10% of people using State-managed mental health services:
- accessed 90% of the hospital care provided, and almost 50% of both ED and care provided by community treatment services. This indicates that a relatively small group of people were consuming the most care. Since the MHC and WA Health have not previously quantified this group of people or analysed their pathways, they are not in a position to know whether their current relatively intensive use of services is meeting patient needs, or whether a different mix of services for this relatively small group could be much more efficient and effective.
- included more older adults compared to everyone that accessed mental health care. Twenty-five percent of them were over 65, compared to 15% of all mental health care consumers. Our analysis found that these people often required care for Alzheimer’s, delirium and dementia. The over-representation of older adults in this group is, in part, associated with the lack of suitable aged care services with appropriate clinical mental health support, resulting in some older adults staying longer in hospital. It would be difficult for the MHC to be confident people are receiving the most suitable and cost-effective care using its current information.
Rather than analysing patient journeys, the MHC and WA Health currently mainly monitor national indicators to measure ineffective care including the 28-day readmission rate key performance indicator (KPI). The 7-day follow-up KPI is also used to gauge the effectiveness of care by measuring the proportion of people who are connected to community services once they leave hospital. These KPIs are intended to indicate when a service may be under pressure or not performing as expected, and can be useful prompts to further investigation.
However, the 28-day readmission rate is at best a blunt indicator that does not take into account that effective care for some people can include planned readmissions. The national reporting framework recognises data limitations that prevent the differentiation between planned and unplanned readmissions for this indicator.
The 7-day follow-up does not reliably capture whether or not a person is actually connected to a community service and in some circumstances does not involve a contact from a community mental health team at all. Instead, it can be the hospital ‘checking-in’ on the person’s wellbeing after discharge through a quick phone call. During the 5 years, follow-up phone calls increased from 34% to 60%, while face-to-face contacts fell from 60% to 30%. This is not reflected in the current KPI.
 Australian Bureau of Statistics, National Health Survey, First Results 2017-18 (4364.0.55.001)
 National Survey of Mental Health and Wellbeing, 2007