The data analysis covered 3 mental health service types: inpatient, ED and community treatment services. People accessed the community treatment services, inpatient and ED care in various combinations over the 5 year period (Figure 4).
Figures 5 and 6 show how people accessed the various combinations of service type each year, by number and by proportion. Figure 5 shows that the total annual numbers increased each year from 65,341 in 2013 to 76,845 in 2017 and that there was very little change in the combinations of how people accessed each of the 3 mental health services.
Figure 6 shows the percentage of the different combinations of access, and that there was only minimal change over the 5 years we analysed. People accessing community treatment services only are the largest group, which accounted for 50% of all people accessing care in both 2013 and 2017. This increased from 32,492 people in 2013 to 38,270 people in 2017.
The biggest percentage change was in Community and ED combination which increased by 41%, from 6,140 people in 2013 to 8,684 people in 2017. This was followed by people who only accessed hospital care which increased by 26% from 1,466 in 2013 to 1,848 in 2017. The number of people who accessed ED only increased by 25% from 10,500 in 2013 to 13,141 in 2017.
The only combinations that experienced a decline were for those people who accessed hospital and ED care (2,482 people in 2013 to 2,247 in 2017) and hospital and community care (2,953 in 2013 to 2,864 people in 2017).
The percentage of people who accessed each of the 3 types of care at least once was relatively consistent, being 14% in 2013 and 13% in 2017.
How much care people accessed, and how often
We also tested if it was possible to analyse how much care (by time) people accessed, and how often they accessed it. This type of analysis could provide insights into how people use the mental health system, and the degree to which services are meeting needs. After consultation with clinicians and DoH analysts we developed 4 access categories for our analysis across the 5 years. These types of categories could potentially prove useful in understanding the interplay between the intensity, severity and acuity of illness, need and service provision.
This type of analysis may also provide the DoH and the MHC with information about whether services are reaching people with severe mental health issues which is the cohort that, under the national planning framework, State funded services are intended to provide care for. This should not be taken as a prescriptive set of categories, but they allowed us to explore some patterns in people using care.
The categories were:
- people who had accessed more than 30 days of care
- people who had accessed less than or equal to 30 days of care over more than one episode
- people who had accessed less than or equal to 30 days of care in one episode
- people who had no more than one day of care over the 5 years.
The analysis showed that of the 212,679 people who accessed State-managed care in the 5 years, 45% had a single State-managed mental health episode lasting between less than one day (30%) and no more than 30 days (15%) (Figure 7). These people may have accessed care elsewhere, such as via their general practitioner, NGO or private psychologist, but we did not have access to the data for those services.
10% of the people that accessed State-managed mental health care from 2013 to 2017 accessed a significant amount of all three services
In the 5 year period, 90% of the inpatient days were used by 10% (21,268) of the people who accessed care. A total of 1,595,182 inpatient days were accessed within the period. Inpatient days were days in hospital where people were admitted for mental health care.
The 21,268 people used 1,434,704 days of this care across 70,573 stays in hospital, which accounted for 60% of all hospital stays.
The same 21,268 people also used 49% of the hours of mental health care provided in EDs, and 47% of the hours provided by community treatment services.
Older adults (people over 65 years of age) were over-represented in the 21,268 people compared to all people who accessed services (Figure 8). Even though they made up only 15% of the total number of people who accessed care, they made up 25% of the 21,268 people who accessed significant amounts of the 3 services we analysed.
Community treatment services
From 2013 to 2017, a total of 155,655 people accessed care from community treatment services. The number of people accessing community treatment services annually grew by 17% from 50,872 in 2013 to 59,567 in 2017. The number of community treatment service events also grew by 17% from 825,127 in 2013 to 965,043 in 2017. Over the same period, the total hours of care provided annually by community treatment services provided fell from 586,335 to 550,829 (6.1%). From 2013 to 2017 the average amount of care provided by community treatment services per person annually decreased by 20% from 11½ hours to 9¼ hours (Figure 9).
From 2013 to 2017, a total of 58,620 people spent 1,595,182 days in hospital beds across 117,615 stays, where the primary reason for care was mental health related. A stay in hospital can start in one year and finish in another year. Where a stay overlaps more than one year, the person is counted once in each year that the stay overlaps. For example, a person who was hospitalised from December in a year to January the following year would be counted once in both years. As a result, the annual totals cannot be added to give a total number of people who accessed hospital care over the entire period. The same logic applies to stays, in that the number of stays in each year can not be added to obtain the total number of stays for the 5 years.
The pattern shown in the graphs below (Figure 10) is the percentage change from 2013 in people, number of stays and inpatient days per year.
We analysed the data to see how many people had long inpatient stays. The MHC has a target that the average length of stay in an acute mental health bed should be less than 15 days. We recognise that not every case will fit the target stay so we looked for stays that lasted 100 days or more to identify significant outlier events that may reveal systemic impacts or drivers of care delivery.
Over the 5 years we analysed, a total of 1,480 people had at least one stay in hospital that lasted 100 or more days. The number of people who stayed in hospital more than 100 days declined from 549 in 2013 to 495 in 2016 (Figure 11).
In 2017, the number of people who had a long stay in hospital was 389 (Figure 11). However, this figure is not comparable to the values reported in the previous years. Calculating long stays requires data that extends for at least 100 days beyond the end of each year, into the following year. Since the dataset ends as at 31 December 2017, the long stay statistics for 2017 cannot be compared with previous years. The figure reported for 2017 is an under-estimate of the actual number of people who had a long stay.
The number of people reported in any year indicates that during that year those people had either begun or continued a stay that lasted 100 days or more. Using this representation, people whose stay stretched across multiple years, are counted in each of those years and as a result the yearly totals cannot be added to give a cumulative total across five years.
Only around a quarter of the total inpatient days resulting from long stays were at Graylands Hospital which includes long-stay wards.
From 2013 to 2017, 126 people had a stay in an acute mental health hospital bed that lasted 365 or more consecutive days. These people consumed 82,874 inpatient days and cost the State an estimated $115 million. In total 284 people spent an accumulated 365 days or more over the 5 years in acute mental health hospital care.
As part of our analysis, we identified 41 people who had been in hospital for at least 5 years where the primary reason for hospitalisation was mental health related. These people had either been in hospital for the entire 5 years we reviewed and were still in hospital on 31 December 2017, or had been in hospital for at least 5 years prior to being discharged during the report period.
A total of 118,532 people accessed mental health care in a public hospital ED from 2013 to 2017. These people presented to ED 253,308 times during the period. Over the 5 years, the number of mental health ED events per year increased by 27%, from 43,965 in 2013 to 55,770 in 2017. The total hours of mental health care provided in EDs per year also increased by 27%, from 264,388 hours in 2013 to 336,698 hours in 2017 (Figure 12).
We compared the time people spent in ED for a mental health presentation to the outcome of the ED event (Figure 13). To do this we categorised outcomes in 4 ways:
- not being admitted into hospital
- being admitted into a general hospital bed (because in some instances, people requiring mental health care are admitted to general hospital beds)
- being admitted into an open mental health bed
- being admitted into a secure mental health bed.
The analysis showed that the time spent in ED was very similar for people who were either not admitted into hospital or were admitted into a non-mental health bed (general hospital bed). People who were admitted from ED into either an open or secure mental health bed spent longer in ED. As Figure 13 shows, time spent in ED for the 4 categories of outcomes varied over the period, but the time spent by people in ED before admission to a mental health bed was longer than those not admitted or those admitted to a general hospital bed in each year.
 This number differs from the 21,000 referred to on Access to State-Managed Adult Mental Health Services report page 30, the variance is a result of rounding.
 Auditor General’s Report 4 of 2019 Access to State-Managed Adult Mental Health Services page 25
 Auditor General’s Report 4 of 2019 Access to State-Managed Adult Mental Health Services page 25