MEDICUS MARCH 2016

O P I N I O N

Associate Professor David Mountain AMA (WA) Emergency Medicine Representative

T o be honest, it is pretty simple to know what psychiatric patients stuck in our emergency departments need – a way out, and perhaps more importantly, avoiding being funnelled into EDs in the first place. The reason the ED has become a default psychiatric service provider of last, and sometimes the only, resort, has been the continued loss of acute psychiatric beds, staff and resources at the same time as community-based services have remained over sold, under resourced and persistently fragmented. It is difficult to know how much underlying psychiatric demand has increased but the use of EDs for psychiatric/drug and alcohol patients has been increasing at 5-6 per cent a year for a decade. This is well ahead of population growth and demand from similar aged patients. Patients are brought to the ED often because there are no alternative resources to look after the acutely mentally unwell in the community. Very little operates outside the M-F, 9-4 hours beloved of NGOs, administrators and non-acute services. But severely mentally unwell patients, suicidal youth and drug-affected patients tend to occur more frequently in the wee hours and on weekends. Demand on EDs has also been increased because of increasing use of stimulant drugs, fragmented community services with inadequate opening hours and poor access to senior clinical staff, particularly Psychiatrists. The police have become more averse to keeping behaviourally disturbed patients at the

Without good acute community

lock up, and psychiatric units rarely accept patients for direct assessment anymore even when patients are formed. This is because as access to beds has become so poor, they do not want patients arriving who can’t be placed, who are also often unwell, agitated, intoxicated and potentially aggressive. At the other end, of course, the ability to get patients out of ED to appropriate care has also been severely compromised by a fixation with reducing acute services both in hospitals and the community. This means many patients, particularly if you are adolescent, disabled or elderly, may be stuck for days in an ED, a psycho- toxic environment, often ending up with the sickest patients having multiple restraints and/or sedation episodes and certainly not starting a therapeutic journey to recovery. The blockage is for the same reason that patients are funnelled to the EDs – there are not appropriate numbers of locked or acute beds either in hospitals or in the community. Step-down services in WA are poorly supported, often unavailable 24 hours a day and with poor access to specialist care. Without good acute community care services, acute units are unwilling to discharge patients into fragmented NGO-led services where both lack of timely support or well- trained staff will compromise patient recovery or lead to further admissions. If PHNs are to be meaningfully involved in transforming the mental health system, they cannot content themselves

with being players just in the non- acute, weekday areas of psychiatric care. They must look at how they can extend services and make current systems improve for the sickest patients, providing extended services in the community to both assess and manage patients to avoid admissions. They also need to be able to accept patients early from acute units whilst providing a complete care package that provides timely and comprehensive clinical follow-up. Non comprehensive services that just pick bits and pieces of care have served WA mental health patients poorly. Joined-up services that are available to all at all times, to all types of patients, when they are in crisis or recovering are what are required to both reduce the need for ED attendances and to unblock the system at the other end. Anything else is just playing around at the margins and will waste money, time and lives and achieve nothing useful. ■ care services, acute units are unwilling to discharge patients into fragmented NGO-led services where both lack of timely support or well-trained staff will compromise patient recovery

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