A failed experiment: Substitution of acute inpatient beds by sub-acute community residential beds in South Australia

To the Editor

I read with interest the recent articles about acute/sub-acute beds (Siskind et al., 2013; Allison et al., 2014). Based on my experience as a hospital-based psychiatrist working in a South Australia (SA) regional sector that lost 19 acute beds substituted by 15 sub-acute beds, the wait times for acute mental health admissions in our local ED have increased significantly. This has raised significant concerns and questions about the sub-acute bedded model particularly in relation to the acute/sub-acute bed mix. The sub-acute beds in SA are located in the community and are designed to simulate residential conditions and only admit voluntary patients with essentially a low risk profile (ICC Operational Guidelines).

The replacement of acute beds with a sub-acute bedded service, with an emphasis on de-medicalization, was flawed. Having exclusive selection criteria together with a length of stay (LOS) capped at 21 days has meant that a cohort of inpatients remain unnecessarily in acute beds contributing to bed block (ICC Operational Guidelines). Such excluded patients include those with complex accommodation needs and patients requiring extended medication supervision and consolidation (e.g. clozapine). These patients cannot easily access a rehabilitation bed or 24-h supported accommodation due to their limited availability in SA. This capped LOS is at odds with the concept that patients should receive the right level of care at the right time.

Acute units are encouraged to ‘step down’ patients to the sub-acute unit in order to be responsive to significant daily bed demands for patients waiting in the ED. Patients are generally declined for transfer to the sub-acute bed if they do not fit the 21 day capped limit and/or recovery-based model of care. Instead patients nearing discharge have become the default and preferred step-down cohort to create an acute bed. However, it is often not acceptable for these patients, their families or clinical staff to consider ‘step-down’ as all parties supported the care episode to be efficiently and effectively completed in the acute ward with the same treating team and psychiatrist. My overall impression is that ‘step-down’ of such patients has unnecessarily extended the overall combined bedded LOS (acute and sub-acute) and an overall inefficient model of care.

In my opinion the substitution strategy of reducing acute beds to fund sub-acute beds has clearly not worked in SA resulting often in mental health patients waiting for days in the ED and wider impacts on the whole healthcare system.