In March 2006, a national snapshot was undertaken of Australian hospital mental health units. Not all jurisdictions participated, and the findings were never published.
However, as you can read below, the survey suggested that 44 per cent of all available public mental health beds were assessed as being occupied by patients not needing acute hospital care and better cared for in other settings.
Given the Rudd Government’s recent announcements aimed at keeping diabetes patients out of hospital by improving their care in the community, why isn’t there a similar focus on improving the community-based care of patients with mental health problems?
This is the question raised below by a regular Croakey contributor, Sebastian Rosenberg. He writes:
“I do not wish to denigrate the Federal Government’s recent announcement of $436m for new services and incentives designed to keep people living with diabetes out of hospital through preventative and primary health care. As an overweight male with a liking for nougat, such an act would represent plain folly.
In making the announcement Prime Minister Rudd drew on a “killer fact” from a table prepared by the Australian Institute of Health and Welfare (Hospital Statistics 2007-08, page 357) showing 237,000 potentially preventable hospital admissions for diabetes complications. According to the theory, proper community-based care should obviate the requirement for expensive and wasteful hospital care.
The same data set showed 175,000 inpatient admissions in 2007-08 for mental illness into Australian hospitals. Importantly, the length of stay for mental illnesses was much longer than for diabetes-related illness, with an average length of stay per episode of 14.8 days versus around 4.8 days for diabetes-related illness (excluding same day stays, Table 12.1). Mental illness required over 2m occupied bed days in Australian public hospitals in 2007-08. Despite its prominence in the hospital system, how far mental illness is from the mindset of ‘prevention’ is illustrated by the fact that it is not listed at all as ‘potentially preventable’ by the AIHW (unlike asthma, hypertension etc).
However, we can draw on other information to illustrate the same point for mental illness as made by Prime Minister Rudd in relation to diabetes.
In March 2006, a national snapshot survey of Australian hospital mental health units was undertaken (never published). Not all jurisdictions participated, most notably NSW.
The key finding of this survey indicated that nationally, 44% of all available public mental health beds were assessed as being occupied by patients not in fact needing acute hospital care and better cared for in other settings. However, these patients were unable to be moved due to lack of community-based alternatives. I understand this figure was 55% in Queensland and 30% in Victoria.
Victorian clinicians of course have some more options than in other parts of the country and, in a very limited way are able to discharge patients from acute care to the supported community care provided by Victoria’s Psychiatric Disability and Rehabilitation Service (PDRS) sector. I say limited because while annual expenditure across the whole of Australia’s mental health system (including hospitals, drugs, Medicare etc) is now around $5bn, the largest PDRS sector in Australia (Victoria’s) receives only around $100m per annum. The total expenditure on this type of care represents an extremely small fraction of the total spending on mental health in Australia each year, probably around 5%.
Based on the national average from the snapshot survey, setting up alternatives to acute inpatient mental health care could result in removing 77,000 hospital admission for mental illness or 880,000 bed days from the system. The same AIHW report indicates that in 2007-08, major diagnostic category 19, Mental Diseases and Disorders, accounted for expenditure of nearly $870m in the public sector alone. On this basis, there is expenditure of around $380m per year tied up providing acute hospital care to patients better cared for in other settings.
So as the PM now announces a set of new measures designed to keep diabetics out of hospital, I can’t help but feel like the filmic cafe patron sitting adjacent to Sally as she orgasmically met Harry: I’ll have what she’s having!
Of course diabetes does have several critical advantages over mental health. There is no stigma associated with managing diabetes. Along with the more effective and convenient treatment options now available, this may be one reason why treatment rates for diabetes have been steadily increasing in Australia for some years.
This is not the case with mental illness. The 1997 National Survey of Mental Health and Wellbeing stated that 38% of people were in receipt of care but by 2007, the repeat survey showed this figure as 35%. Australia has palpably failed to lift the rate of access to mental health care.
Another critical advantage for diabetes over mental illness is that astute diabetic care can largely be managed within and by the health sector. Effective assistance, particularly for people with severe mental illness requires a level of cooperation between sectors, governments and health professions that has so far proved largely elusive.
Perhaps most interestingly, the Prime Minister’s plan for diabetes seems to set out a range of new performance measures, establishing a new system of accountability built around the primacy of effective community and self-management of diabetes and avoiding hospitalisation. This is a system long called for by the mental health sector, a Senate Inquiry and consumers and carers. Measuring the extent to which people with a mental illness are able to live successfully in the community would provide a key stimulus to the development of the services people need – what gets measured gets done. However, 17 years after the first National Mental Health Plan, no such system of meaningful accountability yet exists.
The broadening of service options for diabetes management in the community is to be warmly welcomed but sits in stark contrast to hospital-centric acute care focus which pervades mental health.
Federal reform of diabetes shows they are thinking about community-based models of care. In mental health they still can’t decide whether it is in scope.”
• Sebastian Rosenberg is Senior Lecturer, Mental Health Policy at the Brain and Mind Research Unit, University of Sydney and a member of the Preventative and Community Health Committee of the National Health and Medical Research Council.