Mental health services in Australia

Seclusion is defined as the confinement of a patient at any time of the day or night alone in a room or area from which free exit is prevented. The purpose, duration, structure of the area and awareness of the patient are not relevant in determining what constitutes seclusion.

Seclusion also applies if the patient agrees to or requests confinement and cannot leave of their own accord. However, if voluntary isolation or ‘quiet time’ alone is requested and the patient is free to leave at any time then this social isolation or 'time out' is not considered seclusion.

While seclusion can be used to provide safety and containment at times when this is considered necessary to protect patients, staff and others, it can also be a source of distress; not only for the patient but for support persons, representatives, other patients, staff and visitors. Wherever possible, alternative, less restrictive ways of managing a patient’s behaviour should be used, and hence the use of seclusion minimised.

Seclusion and restraint may be used across the range of mental health services; however, the focus of the national data collections to date has been limited to the acute specialised mental health hospital service setting, since this service setting has been the focus of many of the associated quality improvement initiatives.

Overview

In 2017–18, there were 11,315 seclusion events nationally in public sector acute mental health hospital services, which represents 6.9 seclusion events per 1,000 bed days; a decrease from 11,937 seclusion events, or 7.4 seclusion events per 1,000 bed days in 2016–17. This continues the downward trend observed since 2009–10 (the first year of full national data collection – a rate of 13.9 seclusion events). Over the period from 2013–14 to 2017–18 there has been an average annual reduction in the rate of national seclusion events of 4.3%.

States and territories

In 2017–18, the Northern Territory had the highest rate of seclusion in public sector acute mental health hospital services, with 22.0 seclusion events per 1,000 bed days, compared with Western Australia which had the lowest (4.3). Seclusion rates have fallen for more than half of the states and territories between 2016–17 and 2017–18 (Figure RP.2). While the seclusion rate for the Australian Capital Territory has been consistently lower than the other states and territories, an above average number of seclusion events for a small number of clients resulted in the seclusion rate doubling in 2017–18. However, data for smaller jurisdictions should be interpreted with caution as small changes in the number of seclusion events can have a marked impact on their overall seclusion rate. Further data quality information can be found in the data source section.

Figure RP.2 Alternative text - Source data: Restrictive practices tables 2017-18 (493KB XLS).

Notes: The increase in the state-wide Tasmanian seclusion rate for 2012–13 and 2013–14 data, and for the ACT in 2017–18 are due to a small number of clients having an above average number of seclusion events. Victoria's service delivery model produces a higher threshold for acute admission and the seclusion and restraint metrics may be inflated compared to other jurisdictions. Due to the low ratio of beds per person in the NT compared with other jurisdictions, the apparent rate of seclusion is inflated when reporting seclusion per bed day compared with reporting on a population basis. In addition, high rates of seclusion for a few individuals have a disproportional effect on the rate of seclusion reported.

Frequency and duration

Frequency and duration of seclusion events were collected for the first time in 2013–14. The Australian Capital Territory was unable to provide the number of admitted patient care episodes and, as such, the national results for the frequency of seclusion during episodes of care is limited to those states and territories that can supply data. Duration data for South Australia is also excluded from the national average duration due to issues with the data recording methodology used in South Australia.

About one in 26 (3.8%) episodes of care provided by in scope Australian public sector specialised acute hospital services involved a seclusion event in 2017–18, a decrease from 2013–14 (5.4%). The Northern Territory had the highest proportion of episodes with a seclusion event (16.3%), while Queensland had the lowest (2.4%). Nationally, there were on average 2.1 seclusion events per episode of care with seclusion, which has remained relatively stable since 2013–14 (2.1).

The average duration of a seclusion event, excluding Forensic services, was 5.1 hours in 2017–18, down from 6.0 hours in 2013–14. Forensic services provide services primarily for people whose health condition has led them to commit, or be suspected of, a criminal offence or make it likely that they will reoffend without adequate treatment or containment. Forensic service data has been excluded as forensic seclusion events are typically of longer duration, and substantially skew the overall duration average. Victoria reported the longest average seclusion duration of 8.3 hours per seclusion event in 2017–18, compared with Western Australia (2.2 hours) which had the shortest (Figure RP.3).

Figure RP.3 Alternative text - Source data: Restrictive practices tables 2017-18 (493KB XLS)

Notes:

• South Australia report seclusion duration in 4 hour blocks which precludes average seclusion duration calculations.
• Queensland and the Northern Territory do not report any acute Forensic services, however, forensic patients can and do access acute care through General units.
• The Australian Capital Territory now provides Forensic mental health acute inpatient services as of 2016–17 with the establishment of an acute inpatient service (i.e. Dhulwa Mental Health Unit).
• Victoria's service delivery model produces a higher threshold for acute admission and the seclusion and restraint metrics may be inflated compared to other jurisdictions. Higher acuity on admission may be reflected in an inflated average duration for seclusion events compared to other jurisdictions.

Target population

Seclusion data can also be presented by the target population of the acute specialised mental health hospital service where the seclusion event occurred. Around three quarters (78.0%) of in-scope care (total number of bed days) was provided in General services (unpublished data). Older person services accounted for 14.5% followed by Forensic (3.8%) and Child and adolescent (3.7%) services.

The highest rate of seclusion was for Forensic services with 20.0 seclusion events per 1,000 bed days, followed by Child and adolescent services (8.1), General services (7.4) and Older person services (0.4). The increase in seclusion events in the Forensic target population from 15.0 events in 2016–17 to 20.0 events in 2017–18 is largely attributable to a small number of units in New South Wales, South Australia and Victoria and likely represents improved reporting practices. Although an overall reduction in seclusion rates was observed for most target population categories since 2009–10, some variability is apparent from year to year (Figure RP.4).

Note: Data presented is the target population of the service unit, that is, the age group that the service is intended to serve, not the age of individual patients. In 2013–14, improvements were made to the reporting of target population categories. The Mixed category was removed as an option for reporting. Data for the Mixed category was most commonly a mix of General, Child and adolescent and/or Older person services. Time series data by target population should therefore be approached with caution. Seclusion metrics for a small number of Youth hospital beds reported by Victoria, Queensland, Western Australia, and the Northern Territory are also included in the General category.

Figure RP.4 Alternative text - Source data: Restrictive practices tables 2017-18 (493KB XLS)

Frequency and duration

Forensic services had the highest proportion of episodes of care involving seclusion events, with 25.5% of all mental health-related episodes involving at least one seclusion event in 2017–18. This was followed by General (3.9%), Child and adolescent (2.9%), and Older person (0.8%) services, with all rates relatively stable from 2013–14 to 2017–18.

Forensic services also had the highest frequency of seclusion, with 6.1 seclusion events per episode when seclusion was used at least once during an episode of care. Seclusion events that occurred in Forensic services also had the longest average duration; 57.0 hours per seclusion event, which is much greater than all other target population categories. This may be due to difficulties in applying the seclusion definition to the forensic context. General services reported an average time of 5.3 hours per seclusion event, followed by Older person (5.2 hours) and Child and adolescent (1.3 hours) services. The average time of a seclusion event decreased for General and Forensic services, increased for Older person services, and stayed the same for Child and adolescent services between 2013–14 and 2017–18.

Remoteness

Due to the small number of hospitals located in Outer Regional and Remote areas, for the purpose of remoteness analysis these categories have been combined. There were no hospitals in the seclusion dataset located in Very Remote areas.

In 2017–18, hospitals located in Major Cities had a seclusion rate of 6.9 events per 1,000 bed days. This rate was higher than that for Inner Regional facilities (6.2), and lower than that for Outer Regional and Remote area facilities combined (9.8). The proportion of mental health-related admitted care episodes with a seclusion event was lower in facilities located in Major cities (3.7%), than those in Inner regional areas (3.9%) and Outer regional and Remote areas (5.1%). However, seclusion events in facilities in Major Cities were on average longer in duration (5.3 hours) than those in Inner Regional areas (4.3 hours) and Outer Regional and Remote areas (5.2 hours).

Hospital level data

Figure RP.5 shows the variation in the seclusion rate across Australia in 2017–18. Note that data includes public sector acute mental health hospital services only and excludes forensic units. The variability in seclusion rates between hospitals may be due to a range of factors, such as the hospital’s service delivery model, the number of acute mental health service units in the hospital, the patient casemix, and the target population of the service units.

Figure RP.5 Alternative text - Source data: Restrictive practices tables 2017-18 (493KB XLS).