National mental health report 2013

Changes in inpatient services

Page last updated: 2013

The profile of inpatient services has changed significantly during the course of the National Mental Health Strategy. As noted in Part 1, the First National Mental Health Plan emphasised decreasing the number of psychiatric beds in favour of community‑based options, reducing the reliance on stand‑alone psychiatric hospitals, and ‘mainstreaming’ the delivery of acute inpatient care into general hospitals. Progress against these indicators has been extensively discussed in previous National Mental Health Reports and is presented in a more abbreviated fashion here because the majority of the change occurred during the early part of the Strategy.

In the year before the First National Mental Health Plan was launched (1992‑93), the number of psychiatric beds available in Australia was 7,991 (46 per 100,000). By the end of the First Plan (1997‑98) this had dropped to 6,265 (34 per 100,000), and by the end of the Second Plan (2002‑03) it had reduced further to 6,073 (31 per 100,000). After this, the bed numbers increased slightly in absolute terms but plateaued on a per capita basis. In 2010‑11, mid‑way through the Fourth Plan, there were 6,755 psychiatric beds (30 per 100,000).

Reduction in stand‑alone psychiatric hospitals

To put these reductions in context, Australia, like many other countries around the world, had already instituted a significant process of deinstitutionalisation in the decades before the National Mental Health Strategy began. In the mid‑1960s, when the isolation and detention of people with mental illness in long stay institutions dominated the treatment culture, bed numbers had peaked at around 30,000.

A significant proportion of the reduction in beds is accounted for by ongoing closures of stand‑alone psychiatric hospitals. Between 1992‑93 and 2002‑03, the number of beds in stand‑alone hospitals decreased by 59%, from 5,802 (33 per 100,000) to 2,360 (12 per 100,000). By 2010‑11, there had been a further 5% decrease (to 2,083, or nine per 100,000).

During this period there was a commensurate increase in psychiatric beds located in general hospitals. In 1992‑93, Australia had 2,189 such beds (13 per 100,000). By 2002‑03, this had increased by 70% to 3,713 (19 per 100,000), and by 2010‑11 it had increased by an additional 44% to 4,672 (21 per 100,000).

Changes in the inpatient program mix

The decrease in hospital bed numbers has been accompanied by changes in the mix of inpatient services. Reductions during the National Mental Health Strategy have been selectively targeted at the service type mostly delivered by psychiatric hospitals – that is, hospital wards that provide medium to longer term care. Figure 26 charts the changes in the provision of acute and non‑acute beds from 1992‑93 to 2010‑11. On a per capita basis, the availability of acute beds has remained level (at around 20 per 100,000), whereas the availability of non‑acute beds has dropped (from 25 per 100,000 to 10 per 100,000). There is general consensus that 20 acute beds per 100,000 constitutes a reasonable level of service delivery, whereas there is less agreement about the provision of non‑acute beds and much greater variability across jurisdictions. In part this relates to the varying levels of community residential services that provide longer term care in different states and territories (see above).

Figure 27 provides data on beds available for each of the four target populations served by public sector inpatient units. The denominator has been calculated separately for each group from 2010‑11 back to 1993‑94 (the first year of the National Mental Health Strategy), rather than 1992‑93 (the baseline year used elsewhere). Figure 27 shows that most of the reductions in bed numbers have taken place within adult and older persons’ mental health services, with the former reducing by 29% and the latter by 57%. Beds provided in child and adolescent and forensic mental health services increased in per capita terms by 15% and 25%, respectively, both from a low baseline. Top of page

Figure 26: Acute and non-acute psychiatric inpatient beds per 100,000, 1992-93 to 2010-11

Refer to the following table for a text equivalent of Figure 26: Acute and non-acute psychiatric inpatient beds per 100,000, 1992-93 to 2010-11

Text version of figure 26

AcuteNon-acute
1992-93 Baseline year
21
25
1997-98 End 1st plan
20
14
2002-03 End 2nd plan
20
11
2007-08 End 3rd plan
21
10
2010-11 Mid 4th plan
20
10
Top of page

Figure 27: Total psychiatric inpatient beds per 100,000 by target population, 1993-94 to 2010-11

Refer to the following table for a text equivalent of Figure 27: Total psychiatric inpatient beds per 100,000 by target population, 1993-94 to 2010-11

Text version of figure 27

1992-93
Start 1st plan
2007-08
End 3rd plan
2010-11
Mid 4th plan
General
49
34
34
Child and adolescent
5
5
5
Older person
82
40
35
Forensic
3
4
3
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Changes in the resourcing of inpatient units

A concern expressed at the outset of the National Mental Health Strategy was that the transfer of inpatient services to general hospitals would lead to increased bed day costs and absorb much of the savings potentially available to expand community care.

Analysis of data collected over the period from 1992‑93 to 2010‑11 confirms that the reconfiguration of inpatient services has been associated with significant movement in unit costs. Figure 28 shows the average bed day costs for stand‑alone psychiatric hospitals and for psychiatric beds in general hospitals. Over the 18 year period, the average bed day costs in the former increased by 77% in constant price terms, and in the latter by 51%. The average cost per patient day in stand‑alone hospitals was 23% below that in general hospitals in the baseline year, but by the beginning of the Second National Mental Health Plan was almost equal to it. These costs tracked alongside each other until towards the end of the Third National Mental Health Plan and then diverged again. In 2010‑11, the average bed day cost in stand‑alone hospitals was 9% lower than that in general hospitals.

Economic and clinical factors are responsible for the increase in the costs of hospital care, although the relative contribution of each is not known. Economic factors are implicated in the data shown in Figure 29 which charts resource shifts within Australia’s psychiatric inpatient services over the period from 1992‑93 to 2010‑11. It shows that, at the national level, reduced bed numbers have not translated into reduced overall spending. While the number of beds and the number of bed days have reduced by 15% and 13%, respectively, spending on hospital services has increased by 52%. Direct care staffing levels in inpatient units have increased by 19%, about one third of the rate of growth in overall expenditure on inpatient services. The implication is that inpatient services are substantially more costly than they were at the beginning of the National Mental Health Strategy. When measured in terms of days in hospital, 2010‑11 funding would buy 47% less by way of services than the same level of funding 18 years earlier.

Clinical factors contributing to increased costs include the changing role of stand‑alone psychiatric hospitals. These services have developed specialised roles as they have reduced in size, treating consumers with more complex conditions that require increased staff:consumer ratios. Specific efforts have also been made to bring overall staffing within these hospitals to an acceptable level, commensurate with that provided in general hospital psychiatric units. Data reported by states and territories over the course of the Strategy provide some support for this view, and suggest that average direct care staffing levels within psychiatric inpatient units have increased by 38% (see Figure 30). Top of page

Figure 28: Average costs per day in psychiatric inpatient units, 1992-93 to 2010-11

Refer to the following table for a text equivalent of Figure 28: Average costs per day in psychiatric inpatient units, 1992-93 to 2010-11

Text version of figure 28

General hospitalsStand-alone hospitals
1992-93 Baseline year
574
445
1993-94
547
469
1994-95
537
501
1995-96
573
529
1996-97
582
540
1997-98 End 1st plan
590
561
1998-99
606
594
1999-2000
634
606
2000-01
618
637
2001-02
662
643
2002-03 End 2nd plan
677
665
2003-04
692
677
2004-05
712
679
2005-06
723
684
2006-07
758
683
2007-08 End 3rd plan
789
701
2008-09
823
736
2009-10
832
768
2010-11 Mid 4th plan
867
788
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Figure 29: Changes in the number of psychiatric inpatient beds, patient days, expenditure and direct care full-time equivalent staff relative to 1992-93

Refer to the following table for a text equivalent of Figure 29: Changes in the number of psychiatric inpatient beds, patient days, expenditure and direct care full-time equivalent staff relative to 1992-93

Text version of figure 29

Expenditure
(%)
Direct care FTE
(%)
Inpatient beds
(%)
Inpatient days
(%)
1992-93 Baseline year
0
0
0
0
1993-94
-4
-3
-5
-7
1994-95
-5
-10
-11
-11
1995-96
-9
-15
-18
-20
1996-97
-9
-15
-20
-22
1997-98 End 1st plan
-7
-16
-22
-23
1998-99
-6
-15
-25
-25
1999-2000
-5
-14
-25
-27
2000-01
-3
-14
-27
-26
2001-02
0
-11
-26
-27
2002-03 End 2nd plan
5
-10
-24
-25
2003-04
11
-6
-24
-22
2004-05
18
-3
-22
-20
2005-06
22
3
-21
-18
2006-07
28
7
-20
-16
2007-08 End 3rd plan
34
11
-18
-15
2008-09
41
14
-18
-15
2009-10
45
15
-17
-15
2010-11 Mid 4th plan
52
19
-15
-13
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Figure 30: Average number of direct care staff (FTE) per bed, psychiatric inpatient units, 1992-93 to 2010-11

Refer to the following table for a text equivalent of Figure 30: Average number of direct care staff (FTE) per bed, psychiatric inpatient units, 1992-93 to 2010-11

Text version of figure 30

Direct care FTE per bed:
  • 1992-93 (baseline year) - 1.25
  • 1993-94 - 1.28
  • 1994-95 - 1.28
  • 1995-96 - 1.31
  • 1996-97 - 1.34
  • 1997-98 (end 1st plan) - 1.34
  • 1998-99 - 1.43
  • 1999-2000 - 1.43
  • 2000-01 - 1.48
  • 2001-02 - 1.51
  • 2002-03 (end 2nd plan) - 1.49
  • 2003-04 - 1.54
  • 2004-05 - 1.57
  • 2005-06 - 1.64
  • 2006-07 - 1.68
  • 2007-08 (end 3rd plan) - 1.69
  • 2008-09 - 1.75
  • 2009-10 - 1.75
  • 2010-11 (mid 4th plan) - 1.77