Emergency department–focused mental health policies for people with severe mental illness

[The emergency department is] one of the most visible areas of the interface of psychiatry, health services and the general public, and an area of significant strategic interest for the College.

Kym Jenkins, Immediate Past President of the Royal Australian and New Zealand College of Psychiatry (2019)

It is time for Health Ministers to intervene to ensure equity of access to EDs [emergency departments]. This means that people presenting in mental health crisis get access to inpatient care, or go home linked with the appropriate community follow up, within 4 hours.

Simon Judkins, Immediate Past President of the Australasian College for Emergency Medicine (2019)

Australia’s emergency department mental health crisis

The Australasian College for Emergency Medicine (ACEM) has released a major report on Australia’s mental health system: Nowhere to go: Why Australia’s health system results in people with mental illness getting ‘stuck’ in emergency departments (hereinafter the ACEM Report: https://acem.org.au/Content-Sources/Advancing-Emergency-Medicine/Better-Outcomes-for-Patients/Mental-Health-in-the-Emergency-Department/Nowhere-Else-to-Go-Report). The report is significant for several reasons. First, ACEM joins the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in national advocacy for improved mental healthcare (Jenkins, 2019; Judkins et al., 2019). Second, the report presents a clear case for an emergency department (ED) focus in national mental health policymaking, along with well-defined outcome measures including ED length of stay (LOS). Finally, the report takes a balanced approach to community and hospital services: ‘ACEM will also continue to advocate for governments to increase the amount of inpatient mental health services and community mental health services to ensure that people with mental health needs have sufficient and equable access to appropriate services’ (ACEM Report, p. iii).

People who present to EDs with severe mental health illness (SMI) are regularly spending up to 4–5 days in high-stimulus ED environments while awaiting admission, which may increase their levels of agitation until the patient requires sedation and restraint (Judkins et al., 2019). In response, the ACEM Report recommends that State/Territory health departments adopt a maximum 12-hour ED LOS, with mandatory notification to and review by public hospital chief executive officers (CEOs) of all cases exceeding a 12-hour stay. Furthermore, ACEM recommends that all episodes of more than 24-hour ED LOS should be reported to the relevant Health Minister.

Accordingly, ED LOS would be recognised as a sentinel signal for the shortcomings of Australia’s public mental health services for people with SMI. In 2017–2018, there were over 280,000 mental health–related ED presentations, but considerably fewer presentations (approximately 30,000) resulted in ED stays of longer than 12 hours (Australian Institute of Health and Welfare (AIHW): www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/hospital-emergency-services). Australia-wide, the 90th percentile for ED LOS was 12 hours 24 minutes in 2017–2018, which is above the mandatory notification threshold proposed by ACEM.

Advocating for balanced care

Fundamentally, government underspending for low-prevalence disorders is driving extended ED LOS. In 2017–2018, Australia spent a total of AUD$9.9 billion on mental health–related services with AUD$6 billion provided to State/Territory mental health services (including AUD$2.6 billion for public hospital services and AUD$2.3 billion for community services: www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/expenditure-on-mental-health-related-services). At this level of expenditure, Australia had a low provision of community and hospital services by international standards (Perera, 2020). In particular, Australia provided only 41 psychiatric beds per 100,000 people (28 per 100,000 in the public sector and 13 per 100,000 in the private sector: www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/specialised-mental-health-care-facilities), compared to the Organisation for Economic Co-operation and Development (OECD) average of 71 psychiatric beds per 100,000 (ACEM Report p.3)

The ACEM Report advocates a new policy direction for Australia’s underfunded mental health system – away from proposing community services without associated inpatient services (Allison et al., 2020) and towards a recognition that both hospital and community services are needed in a well-functioning system. From this perspective, hospital and community services are effective complements, not substitutes: community services require responsive inpatient services, and hospital services require timely follow-up by community teams (Perera, 2020).

Thornicroft and Tansella (2013) proposed ‘the balanced care model’ to address the heated debates about the merits of community versus hospital services. And a recent analysis of cross-national data from the World Health Organization (WHO) Mental Health Atlas study suggests that governments of high-income countries practice balanced care (Perera, 2020). There was a positive association between community care (facilities per capita) and hospital care (psychiatric beds per capita):

Generally, countries with high levels of inpatient care also provide high levels of outpatient care (e.g. the Netherlands, France, Switzerland, and Germany). Meanwhile, the countries that provide the least amount of inpatient care (e.g., the United States, New Zealand, Denmark, and Sweden) tend to provide the least amount of outpatient care as well. (p. 965)

Australia and New Zealand had relatively low provision of community facilities/psychiatric beds per capita (Perera, 2020). High-income countries with more psychiatric beds per capita than Australia and New Zealand tended to locate them in standalone specialty hospitals, not general hospitals.

Balanced care is also evident within Australia. While the current Australian policy zeitgeist, as reflected in the National Mental Health Service Planning Framework (NMHSPF), involves raising targets for community services while limiting psychiatric beds per capita (Allison et al., 2020), in practice State/Territory governments appear to balance community/hospital care. First, expenditure on State/Territory services is balanced with AUD$2.6 billion for public hospitals and AUD$2.3 billion for community services. And a 2019 analysis of Access to Mental Health Services by the Victorian Auditor General revealed that State/Territory governments with lower psychiatric beds per capita also tended to have lower provision of community services (contacts per 1000 people), and States/Territories with higher beds per capita had higher community service provision (p. 50: www.audit.vic.gov.au/report/access-mental-health-services?section=33104–audit-overview). Tasmania had the lowest provision of both community and hospital services and also the longest 90th percentile ED LOS. On the contrary, NSW and Queensland had the highest provision of both community and hospital services and the shortest 90th percentile ED LOS.

Implications for ED-focused policies

Extended and dangerous ED LOS are emblematic of major flaws in Australia’s mental health system. The challenge raised by the sentinel signal of ED LOS is no less than to provide comprehensive mental health services across the lifespan with a balance of community and hospital care. Future policies for addressing the ED LOS crisis should include balanced increases in both community/hospital care, recognising these services as complementary, not substitutes. Re-orientation towards balanced community/hospital care would substantially change national policies. For example, the recent draft Productivity Commission Report acknowledged that the ED crisis is due to restricted access to acute inpatient treatment, but the report fell short of recommending a substantial increase in beds per capita to meet international standards (Allison et al., 2020). Future national mental health strategies should implement balanced care: the ED LOS sentinel signal must be heeded, with balanced mental healthcare forthcoming.