Victoria’s low availability of public psychiatric beds and the impact on patients,carers and staff

For decades, governments in high-income countries have made savings by moving long-term responsibilities for severe mental illness (SMI) to unpaid informal carers. As governments closed beds in standalone mental hospitals, financial and emotional burdens were shifted to the families of people with SMI. While community teams offer first-line treatment by visiting patients at home, carers often do the bulk of the work, spending an average of 5–6 hours per day supporting a relative with SMI, saving governments the cost of providing comparable care and accommodation (Yesufu-Udechuku et al., 2015). These daily demands increase the stress on families with deleterious effects on carers’ health, wellbeing, occupational status and finances (Yesufu-Udechuku et al., 2015).

The process of bed closures and burden shifting is well advanced in Australia, where governments have closed most non-acute beds in mental hospitals to fund smaller numbers of acute beds in general hospitals. More recently, Australian governments have begun restricting acute beds, and reducing lengths of stay (Allison and Bastiampillai, 2015; Allison et al., 2017). As public beds reduced, private sector beds became a growth area with an average increase of 9% annually, reaching 11 beds per 100,000 population (Australian Institute of Health and Welfare, 2014–2015: https://mhsa.aihw.gov.au/resources/facilities/beds/). Private beds cater for patients with disorders such as depression who cannot access the public system, but families on low incomes and people with SMI are usually not admitted to private beds. After these shifts, Australia has relatively few beds left (39 public and private hospital-based psychiatric beds per 100,000 population).

Australia ranks 26th of the 35 Organisation for Economic Cooperation and Development (OECD) countries for total hospital-based psychiatric bed numbers (OECD average of 71 beds per 100 000 population: OECD Health Statistics, 2015: http://stats.oecd.org/#). There is wide variation within the OECD with some European countries such as France (87 beds per 100,000 population) and Germany (127 beds per 100,000 population) having far greater inpatient capacity than Australia, and other European countries such as the United Kingdom (46 beds per 100,000 population) and Italy (10 beds per 100,000 population) (Tyrer et al., 2017).

Within Australia, state governments have also adopted widely different polices with the two largest states, Victoria and NSW providing a stark contrast. Victoria spends the least per capita on mental health services (AUD197 versus the Australian average of AUD$219 per capita; AIHW, 2014–2015). Victoria also has far lower numbers of publicly funded hospital-based psychiatric beds for people with SMI (22 beds per 100,000 population) than NSW (36 beds per 100,000 population). The Australian average is 29 public beds per 100,000 population. The World Health Organization (WHO) reports that high-income countries have an average of 42 hospital-based psychiatric beds per 100,000 population, and European countries have an average of 45 beds per 100,000 population (http://apps.who.int/iris/bitstream/10665/178879/1/9789241565011_eng.pdf).

Staff working on the psychiatric wards in Victoria’s underfunded mental health system can experience high levels of stress from managerial pressure for early patient discharge, increasing proportions of involuntary patients and disrupted environments. They must also deal with the systemic challenges of inadequate clinical governance, poor quality and safety monitoring, wide variations in clinical practice and the risks of serious harm to psychiatric inpatients (Newton et al., 2017). Average mental health emergency department (ED) waiting times in Victoria’s public hospitals are well in excess of the 4-hour target, due to the complexity of mental health assessments, and low availability of public psychiatric beds, increasing the pressure on ED staff.

What has been the impact of these system-wide problems on carers? Carers Victoria recently submitted a response to the proposed Victorian Mental Health Plan addressing the issue (www.carersvictoria.org.au/publications/policy-submissions#Section2). Their response was based on feedback from the many carers for people with SMI who identified problems with the public mental health system, and published reports on the effects of psychiatric bed shortages in Australia (Allison and Bastiampillai, 2015; Allison et al., 2017). Carers Victoria stated, ‘If a person in need is unable to access an acute bed, severe emotional or at times physical harm to them and their carer or family is a potential or high risk and can affect the wider community’ (p. 7). While Carers Victoria noted the efforts of community-based services to compensate for low acute bed numbers, they specifically recommended that the ‘(Victorian) Government substantially increases investment in acute beds and coincides this with follow up programs to support people at high risk of readmissions’ (p. 4).

The Royal Australian and New Zealand College of Psychiatrists should join Carers Victoria in advocating for safe minimum numbers of psychiatric beds for people with SMI. This advocacy needs to be evidence-based with studies of the effects of interstate differences in the bed mix especially between Victoria and NSW, international comparisons with other high-income countries, including a broad sample of Western European countries as well as Italy, a systematic review of the research literature, and the opinions of clinical psychiatrists. Psychiatrists should be able to refer a patient in need for timely acute admission when their carer is distressed by a relative’s symptoms, risk profile and behaviour at home. This does not seem to be the case in jurisdictions around Australia.

See Commentary by Allison et al (2017) 51: 191–192.