National mental health report 2013

Expansion of community-based services

Page last updated: 2013

About two thirds of the $2.6 billion growth in annual spending on services to repIace stand-alone hospitals has been invested in expansion of community-based services - most notably ambulatory care services (48%), but also services provided by NGOs (11%) and residential services (6%). The remainder is accounted for by increased investment in psychiatric units located in general hospitals (36%). Each of these developments is described in more detail below.

Ambulatory care

Ambulatory care services comprise outpatient clinics (hospital and clinic-based), mobile assessment and treatment teams, day programs and other services dedicated to the assessment, treatment, rehabilitation and care of people affected by mental illness or psychiatric disability who live in the community.

Figure 18 shows that there has been significant growth in the resources directed to ambulatory mental health care services during the course of the National Mental Health Strategy. Between 1992-93 and 2010-11, there was a 291% increase in expenditure on ambulatory services (from $421 million to $1.6 billion). Over the same period, the full-time equivalent direct care workforce employed in ambulatory settings increased by 215% (from 3,358 to 10,592). In per capita terms, this is an increase from 19.1 per 100,000 population to 47.1 per 100,000 population (see Figure 19).

All jurisdictions have more than doubled their ambulatory care workforce over the course of the Strategy. Two (Western Australia and Queensland) stand out with increases of 307% and 440%, respectively. More detail on jurisdictions' performance can be found in Part 4.

Figure 18 also shows that growth in expenditure has outstripped growth in the direct care workforce, even when inflation is taken into account. The implication is that more dollars have not proportionally translated into increased staffing levels in state and territory ambulatory services. Nationally, the purchasing power of the mental health dollar in 2010-11 was 24% less than in 1992-93 when measured by the number of staff employed in ambulatory care. This may be due to a number of factors, including employment of clinical staff with higher qualifications (and salaries), a greater overall increase in costs in mental health relative to overall health care, or higher administrative overhead costs associated with the process of managing an increasingly complex service system. As noted later in this report, similar cost increases have occurred in inpatient services.

These indicators provide a simplified view of the collective progress of the states and territories. However, they do not tell us about the workforce levels required to meet priority community needs, nor about the amount of care actually provided. The National Mental Health Service Planning Framework, mentioned above, will establish targets for the optimal mix and level of the full range of mental health services, including ambulatory services. Top of page

Figure 18: Changes in resourcing of ambulatory care services, 1992-93 to 2010-11

Refer to the following table for a text equivalent of Figure 18: Changes in resourcing of ambulatory care services, 1992-93 to 2010-11

Text version of figure 18

Direct care staff (%)Expenditure (%)
1992-93 Baseline year
0
0
1993-94
4
11
1994-95
26
27
1995-96
45
53
1996-97
62
70
1997-98 End 1st plan
68
82
1998-99
80
92
1999-2000
88
107
2000-01
95
122
2001-02
109
134
2002-03 End 2nd plan
116
148
2003-04
125
157
2004-05
136
174
2005-06
150
193
2006-07
161
214
2007-08 End 3rd plan
174
238
2008-09
185
258
2009-10
197
277
2010-11 Mid 4th plan
215
291
Top of page

Figure 19: Full-time equivalent (FTE) direct care staff per 100,000 population employed in ambulatory mental health care services, 1992-93 to 2010-11

Refer to the following text for a text equivalent of Figure 19: Full-time equivalent (FTE) direct  care staff per 100,000 population employed in ambulatory mental health care services, 1992-93  to 2010-11

Text version of figure 19

Full time equivalent (FTE) clinical staff per 100,000:
  • 1992-93 Baseline year - 19
  • 1997-98 End 1st plan - 30
  • 2002-03 End 2nd plan - 37
  • 2007-08 End 3rd plan - 43
  • 2010-11 Mid 4th plan - 47 Top of page

The non-government community support sector

The non-government community support sector includes services provided by not-for-profit NGOs, funded by governments to provide support for people with a psychiatric disability arising from a mental illness. The NGO sector provides a wide range of services including accommodation, outreach to support people living in their own homes, residential rehabilitation units, recreational programs, self-help and mutual support groups, carer respite services and system-wide advocacy.

From the outset, the National Mental Health Strategy advocated the expansion of the role of NGOs in providing support services to consumers and carers whose lives are affected by mental illness. Expansion of the sector was promoted as a means to strengthen community support and develop service approaches that complement the clinical services provided by inpatient services and community teams. More recently, the COAG National Action Plan on Mental Health renewed the call to elevate the priority of the NGO sector, and stimulated a major expansion of funding by most jurisdictions.

Figure 20 shows that the overall proportion of mental health budgets allocated to NGOs before the National Mental Health Strategy began was only 2.1%. This share grew during the course of the First and Second National Mental Health Plans, such that by the end of the Third Plan (2007-08), 8.5% of state and territory mental health budgets was directed to the sector. Mid-way through the Fourth Plan, the figure now sits at 9.3%. Total state and territory funding allocated to NGOs in 2010-11 amounted to $372 million, distributed to a broad range of organisations from some very small entities employing only a few workers to complex, multi-million dollar organisations.C

Figure 20 also shows that despite the significant growth in recent years, differences between jurisdictions remain prominent. By 2010-11, the 'NGO share' was strongest in the Australian Capital Territory (17.3%) and lowest in New South Wales (6.0%).

Previous National Mental Health Reports have observed that the role piayed by NGOs varies across the jurisdictions, reflecting differences in the extent to which states and territories fund the organisations that take on the functions that substitute for those traditionally provided by the government sector, or to develop complementary services. In this environment, a diverse array of services has been developed by the NGO sector to meet varied needs. Figure 21 shows the national profile of NGO services funded by states and territories in 2010-11. Psychosocial support services account for about one third of the funding, and staffed residential mental health services account for about one fifth. Top of page

Figure 20: Percentage of total mental health services expenditure allocated to non-government organisations, 1992-93 to 2010-11

Refer to the following table for a text equivalent of Figure 20: Percentage of total mental health services expenditure to non-government organisations, 1992-93 to 2010-11

Text version of figure 20

State1992-93 Baseline year2007-08 End 3rd plan2010-11 Mid 4th plan
NSW
1.4
6.7
6.0
Vic
3.1
11.7
12.8
Qld
1.3
6.8
8.5
WA
2.5
6.5
8.7
SA
1.7
9.5
11.5
Tas
3.2
11.3
13.5
ACT
2.6
14.4
17.3
NT
1.1
13.5
12.1
National
2.1
8.5
9.3
Top of page

Figure 21: Types of services funded by state and territory grants to non-government organisations, 2010-11

Refer to the following table for a text equivalent of Figure 21: Types of services funded by state and territory grants to non-government organisations, 2010-11

Text version of figure 21

  • Staffed residential mental health services 18%
  • Accommodation support services 13%
  • Advocacy services 2%
  • Community awareness/ health promotion 5%
  • Counselling services 3%
  • Independent living skill support services 11%
  • Pre-vocational training and recreation services 1%
  • Psychosocial support services 33%
  • Respite services 2%
  • Self-help support groups 3%
  • Other and unspecified services 9% Top of page

Community residential services

From its inception, the National Mental Health Strategy recognised the central place of accommodation in promoting quality of life and recovery for people Iiving with a mental illness. A wide spectrum of accommodation services is needed, including tenured housing, supervised community residential units, crisis and respite places and flexible support systems that provide assistance to people living in independent settings.

Deficiencies in accommodation options to replace the former role of large stand-alone institutions have been linked to the failure of mental health reform initiatives overseas and were the focus of criticism in Australia by the Human Rights and Equal Opportunities Commission in the period immediately preceding the Strategy. Similar opinions have been voiced by consumer advocacy groups over the course of the Strategy.

The approach taken by previous National Mental Health Reports to monitoring community accommodation under the Strategy has focused mainly on the extent to which each state and territory has developed specialised community residential services, staffed by trained mental health workers, that provide alternative care to that previously available in longer term psychiatric institutions. This report also presents information on 24 hour staffed beds in these specialised services, but augments it with data on services with beds staffed on a less than 24 hour basis. Figure 22 shows that in 2010-11, the number of 24 hour staffed general adult beds was more than double that in 1992-93 (846 compared with 410). The number of 24 hour staffed older persons' beds was also higher in 2010-11 (682) than it was in 1992-93 (414), although it reached a peak in 1998-99 (805) and has been declining since then. Data on non-24 hour staffed beds have not been available for the full period, but have increased since 2002-03 (from 586 to 708) in general adult residential services and remained the same (12) in older persons' residential services.

Development of staffed community residential services has been patchy, with much variation between jurisdictions. Until well into the mid-2000s, Victoria led the way. More recently, however, jurisdictions with very limited early development have begun investing in staffed residential services for adult consumers to fill a widely acknowledged service gap.

Figure 23 compares the jurisdictions on adult and older persons' residential services available in 2010-11. For general services, three jurisdictions -Tasmania, the Australian Capital Territory and Victoria - were the leading providers, standing well above their peers. For older persons' residential services there was greater variability but the same three jurisdictions were marked by their service provision levels relative to other jurisdictions. Victoria in particular is unusual when compared to other jurisdictions in terms of its investment in specific residential services for older consumers. Nine out of ten residential beds for older persons available in Australia in 2010-11 were provided by Victoria.D

At a national level, the growth since 1992-93 in 24 hour staffed residential services (717 beds) is equivalent to only about one quarter of the reduction in longer stay (non-acute) beds in psychiatric hospitals (2,719 beds). The additional 730 beds staffed on less than a 24 hour basis became available during the period and provide partial compensation, but it is not possible to chart how these have developed over the full 18 year period. They have almost exclusively been developed for adults rather than older persons, and provide varying levels of on site supervision, ranging from six to 18 hours per day.

The number of supported public housing places is also relevant here. These places are designed to assist people to live as independently as possible through the provision of ongoing clinical and disability support, including outreach services in their homes. These are seen by consumer advocates as essential components of a recovery oriented system, and provide independent living support to some people who, in 1992-93, might have been in receipt of long stay institutional care. Several jurisdictions are developing individual care and support packages tied to public housing in preference to investing in staffed residential units, arguing that this sort of care is preferred by many consumers. The New South Wales Housing and Support initiative, for example, provides for support packages ranging from low to intensive support, the latter of which have similar costs to individual care provided in staffed residential services.

Figure 24 summarises the data on the availability of supported public housing places over time. It shows that 4,997 such places were available in 2010-11, 87% more than in 2002-03. This equates to 22.2 places per 100,000 in the latter period, an increase of 64% over the 13.5 places per 100,000 that were available in 2002-03.

Figure 25 shows that although all states and territories provided supported public housing places in 2010-11 and contribute to the above national averages, there was considerable cross-jurisdiction variation. Western Australia was the clear leader, with 62.1 places per 100,000. Queensland and Tasmania provided far fewer than the national average, at 6.1 and 4.5 per 100,000, respectively.

There is no national consensus on planning benchmarks for the provision of community residential services or supported housing places. However, there is agreement that such services are an integral part of the full range of community services required to replace the historical functions of the stand-alone psychiatric hospitals. Developments during the Third and Fourth National Mental Health Plans indicate that jurisdictions are undertaking the service development needed to fill gaps that existed when the National Mental Health Strategy began. As noted earlier, the National Mental Health Service Planning Framework will establish targets for residential and supported housing places that will guide future service development. Top of page

Figure 22: Total beds in general adult and older persons' residential services, 1992-93 to 2010-11a

Refer to the following table for a text equivalent of Figure 22: Total beds in general adult and older persons' residential services, 1992-93 to 2010-11

a No graphic is provided for child and adolescent beds because they are very few in number (13).

Text version of figure 22

General adult
1992-93 Baseline year1997-98 End 1st plan2002-03 End 2nd plan2007-08 End 3rd plan2010-11 Mid 4th plan
24-hour staffed
410
632
625
766
846
Less than 24-hour staffed
586
611
708
Older persons
1992-93 Baseline year1997-98 End 1st plan2002-03 End 2nd plan2007-08 End 3rd plan2010-11 Mid 4th plan
24-hour staffed
414
731
782
694
682
Less than 24-hour staffed
12
12
12
Top of page

Figure 23: Number of beds per 100,000 in general adult and older persons' residential services by jurisdiction, 2010-11a

Refer to the following table for a text equivalent of Figure 23: Number of beds per 100,000 in general adult and older persons' residential services by jurisdiction, 2010-11

a No graphic is provided for child and adolescent beds because they are very few in number (13).

Text version of figure 23

General adult
NSWVicQldWASATasACTNTNational
24-hour staffed
2.3
13.7
4.9
7.7
19.5
14.2
9.6
6.0
Less than 24-hour staffed
0.5
9.7
14.0
1.8
24.6
15.4
5.0
Older persons
NSWVicQldWASATasACTNTNational
24-hour staffed
1.8
81.9
39.6
13.2
22.5
Less than 24-hour staffed
1.2
0.4
Top of page

Figure 24: Growth in supported public housing places (absolute and per 100,000), 2002-03 to 2010-11

Refer to the following table for a text equivalent of Figure 24: Growth in supported public housing places (absolute and per 100,000), 2002-03 to 2010-11

Text version of figure 24

2002-032007-082010-11
Number of places
2676
3953
4997
Number of places per 100,000
14
19
22
Top of page

Figure 25: Number of supported public housing places per 100,000 by state and territory, 2010-11

Refer to the following text for a text equivalent of Figure 25: Number of supported public housing places per 100,000 by state and territory, 2010-11

Text version of figure 25

Number of places per 100,000:
  • NSW - 22
  • Vic - 23
  • Qld - 6
  • WA - 62
  • SA - 15
  • Tas - 5
  • ACT - 13
  • NT - 25
  • National - 22 Top of page

Footnotes

C Prior to 1999-00, all services provided by non-government organisations were reported only in terms of total funds allocated by state and territory governments. Commencing in 1999-00, staffed community residential units managed by the sector began to report separately and were grouped with 'government managed' residential services in previous National Mental Health Reports. For the purposes of the analysis in this section, funding to NGO-managed staffed residentiaI services (approximately $66 million in 2010-11) has been combined with non-residential NGO programs to ensure better consistency in monitoring the 18 year spending trends. The 2010-11 estimate of 9.3% of expenditure allocated to NGOs described in this section differs from the 7.6% shown in Figure 17 because, in the latter, NGO-managed residential programs are grouped with other residential services.

D Caution is required w hen interpreting residential services data for Queensland. A substantial number of general adult beds in Queensland that meet the definition of beds in staffed residential services were reported by Queensland as non-acute inpatient beds.