The Plan identified gaps in the mental health service mix that for some people meant their available care pathway necessitated more intensive and higher cost care settings than required, usually a hospital. These gaps largely remain and the reliance on hospital services has continued, making services less accessible and less efficient.
An acute specialised mental health bed costs $1,500 a day, 3 times the cost of the most expensive non-hospital facility
Hospitals provide a significant amount of mental health care, and this generally involves 1 or more presentations to an ED and an admission to a hospital bed. The average length of stay in an acute hospital bed is intended to last less than 15 days and help stabilise people with severe mental health issues. An acute hospital bed is estimated to cost the MHC $1,500 a day (Figure 5), 3 times the cost of community based higher acuity facilities.
Expanding the care options between current community services and hospital care, as intended in the Plan, would provide people with more cost-effective, accessible and personalised care options and help to reduce the unsustainable reliance on hospital beds.
People staying in acute beds for long periods reduces the number of beds that are available, making it more difficult for others to access services
The MHC’s target for an average length of stay in an acute hospital bed is less than 15 days. While the MHC expects that some people will require a stay longer than the 15 days in line with their support needs, groups of people who stay significantly longer than 15 days highlight where the use of services does not match the model of care. This pattern may also indicate difficulties in accessing more appropriate care settings.
Using WA Health’s data from 2013 to 2017, we found 284 people had spent at least a year in an acute mental health hospital bed. Of the 284 people, 126 had spent more than 365 consecutive days in an acute hospital bed, costing the State an estimated $115 million. Less than one third of these long stays in acute beds resided at Graylands Hospital for the entire stay. The other 158 people had multiple stays in an acute hospital bed that in total were longer than a year.
Acute beds are intended to stabilise people over a short period of time and not provide long term clinical treatment. Moving people requiring long-term clinical care into more appropriate alternative care settings would effectively increase acute bed capacity in hospitals without expanding bed numbers. It would also improve access to care for those who need short-term stabilisation. However, the alternative options to long-term clinical care are currently limited. There are 2 hospitals that have sub-acute beds. These provide clinical care with a longer length of stay, but are not intended to provide the years of support needed by some people. The MHC reported it purchases 177 long-term residential mental health beds from non-government organisations with clinical support, but we still saw in our data analysis people staying in acute beds for extended periods of time.
Providing options for people needing long-term clinical care out of hospitals is more cost effective. The State currently has Jacaranda House, which provides long-stay mental health care for people with enduring, severe mental illness. This service consists of 5 beds and is managed by the East Metropolitan Health Service (EMHS). Under the Service Agreement between the MHC and the EMHS, beds at Jacaranda House cost around $435 a day, over $1,000 less than a bed day in an acute hospital bed. Because the service is standalone and has clinical input from the hospital, the people who live there are able to receive care specific to their needs.
In its 2003 publication Organization of services for mental health, the World Health Organization reported that an extremely small number of people will always need acute long-stay services. Our analysis of WA Health data showed that 41 people were either in State-managed hospital for the entire 5-year period or had completed a stay that lasted longer than 5 years. Acute long-term services are where people with extremely severe mental health needs can both reside and receive intensive mental health care. This care is necessary even with good quality community treatment services available, and is best provided in small units within the community. Unless this type of care is available, these people are likely to seek care in a hospital, a higher cost care setting than other clinically appropriate options.
The current service mix increases the pressure on EDs
For the people who use State-funded mental health services, their mental health issues can be episodic with periods of relative wellness punctuated by occasional deterioration and sometimes crisis. This pattern often goes on for years. The Plan set out a mix of services to allow people to escalate the intensity of care as their mental health deteriorates. However, continuing gaps in the range of community-based services make it difficult for people to do this, and result in them seeking care through EDs. This is often not the most appropriate care setting for them, and increases the pressure and cost in EDs.
Almost half of the people who first accessed State-managed mental health services from 2013 to 2017 made their first contact with these mental health services through an ED. People sometimes have to present to an ED more than once to access care. We found 2,278 people who had 3 or more ED visits in the week before they were admitted to hospital for mental health care. Some people had this issue more than once. For example, 9 people had more than 10 ED presentations in the week leading up to an admission, sometimes presenting multiple times a day before accessing a bed.
The time it takes to address mental health ED presentations is longer than for general medical presentations, which exacerbates the impact on EDs. From 2013 to 2017, mental health ED presentations accounted for 5% of the total presentations to EDs, yet accounted for 10% of the total care time provided in EDs. The MHC does not fund the mental health care delivered in EDs because it is not considered a specialised mental health service, and the cost of it is not separately captured by WA Health or the MHC.
More people are accessing community treatment services, but overall capacity has not increased, so on average people are receiving less care
Between 2013 and 2017 there was a 17% increase in the number of people accessing community treatment services. Over the same period, there was a 6% decrease in the total hours of care provided by those services. Increasing the number of people accessing community treatment services is consistent with the intent of the Plan. But the lack of growth in funding and capacity has meant a 20% reduction overall in the hours of care provided per person (Figure 6). So more people are getting less care from community treatment services overall.
Seeing more people within the same resources could indicate improved efficiency in community treatment services. However, to evidence this the MHC would need to demonstrate that quality of service has been maintained. We did not see any data to demonstrate the evaluation of service quality. The clinicians we consulted believed that services were struggling to meet the increasing demand.