Intense pressure on the Royal Hobart Hospital after psychiatric bed cuts

The Royal Hobart Hospital (RHH) has a proud history, commencing service in 1804, and moving to its current site in 1820. The hospital provides a full suite of tertiary healthcare services, including acute inpatient care for those suffering with psychiatric illness in the south of the state. However, much of the hospital is outdated, and significant renovations have been undertaken, with a major new tower currently being built. To accommodate the new tower, an older block was demolished. This block had housed 42 general adult (aged 18–64) acute psychiatric beds in total, an 8-bed psychiatric intensive care unit, and a 34-bed open unit, which catered for a general adult population of just under 160,000. These units had adequately catered for the needs of the local adult population for nearly 20 years and were only occasionally bed-blocked.

For many years, acute psychiatric services at the RHH were managed internally by the RHH. More recently, however, the management of these services was taken over by an external public mental health services management team. Prior to the old block being demolished, the new management team carried out some work to determine the number of beds needed for the unit and decided that only 30 beds were required. These bed numbers were used in the design of both a temporary demountable unit and a long-term unit in the new tower.

Aware that the Southern Tasmanian catchment area would need at a minimum 38 acute adult psychiatric beds to remain at the current national general adult acute bed average (Australian Institute of Health and Welfare [AIHW], 2014–2015: https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/mental-health-resources/specialised-mental-health-care-facilities), senior clinicians, the Royal Australian and New Zealand College of Psychiatrists (RANZCP), the Australian Medical Association (AMA) and the Australian Nursing and Midwifery Federation (ANMF) all lobbied the government to increase the number of beds, as a matter of urgency. These advocacy attempts were largely unsuccessful: the temporary demountable unit has only 32 beds, and the more permanent unit will have only 33 beds. Both are designed with six high dependency unit beds. The Southern Tasmanian region now has approximately 20.4 general adult acute psychiatric beds per 100,000 population, while the national average is 24.2 general adult acute beds per 100,000 population, and NSW, the state with the highest number of beds (Allison et al., 2018), has 28.8 general adult acute beds per 100,000 population.

Beds in the old acute wards were gradually closed, and the new temporary unit, with only 32 acute beds, was opened in November 2016. As anticipated, the RHH reached a tipping point (Allison and Bastiampillai, 2015), and bed block began to appear during the transition period. Since early 2017, the demountable unit has not only been almost permanently bed-blocked, there are always a high number of acutely psychiatrically unwell patients waiting in the Emergency Department (ED) for extended periods, often for several days. High rates of acute situational crises due to high levels of psychosocial adversity in Tasmania, and the increasing abuse of crystal methamphetamine, add to the mental health demand in the ED.

Morbidity and mortality have increased, and, in late 2016, the Coroner concluded in one case that, ‘Had sufficient beds been available in the mental health ward of the RHH then doubtless he would have been admitted and it is likely that he would not have taken his life’ (http://www.magistratescourt.tas.gov.au/about_us/coroners/coronial_findings, Mr S, November, 2016). This suicide is important to put in local context: Tasmania now has the highest suicide rate of all Australian states, at 17.0 per 100,000 in 2016, in comparison to the Australian average for that year of 11.7 per 100,000 (ABS statistics, 2017). Clinicians fear that patients will continue to suffer serious adverse outcomes due to the reduced access to inpatient care (Bastiampillai et al., 2016).

The Tasmanian Government continues to state that the number of acute adult psychiatric beds in Hobart is appropriate and that the focus of care should be within the community (ABC television news, 1 June 2017). The Binational RANZCP Committee for Training, the body that oversights the training of psychiatric registrars across Australia, however, withdrew accreditation for all training posts at the RHH acute adult psychiatric unit in August 2017, seriously concerned about the welfare of trainees in the unit, with excessive and unpredictable workload due to bed block resulting from the reduction in bed stock being one of a number of significant factors involved.

As a result of the significant bed block, the loss of accreditation and sustained advocacy, the government has employed more medical staff and had proposed a plan to open a five-bed observation unit at the RHH for low-risk, short-stay patients. The plan for the unit was controversial, however, as the unit was not co-located with the ED and accommodated all of the patients in one room, with little amenity. In addition, the extra beds did not result in Southern Tasmania meeting the national average for general adult acute psychiatry beds. The plans for the unit were withdrawn during consultation, and solutions for bed block are still being sought.

It is vital that those planning acute mental health units appropriately cater for the local population needs. As such, the RHH should ensure that at least 42 acute adult psychiatric beds (36 open and 6 high dependency) are always available on its city campus. It should be noted, however, that these calculations do not take into account any loading for the extra mental health difficulties associated with poorer socioeconomic indices in Tasmania, any increases in the number of acute psychiatric presentations or any population growth and fall well short of current NSW bed numbers.