Hickie as Vladimir, McGorry as Estragon. As in Beckett’s play about the mythical Godot, mental health reformers waited, like everybody else, to see if Ruddo would actually turn up. He didn’t. Yesterday may have been an historic occasion for patients but for only some of them. For the four million Australians who have a mental illness, the wait for real investment in mental health reform just goes on.

We should all have known better than to get our hopes up. An 11th hour commitment by Minister Roxon on Lateline to take over all community mental health services is now a commitment to work with the states and come up with another plan in 2011. This is better than nothing.

Large sums of cash are being described right now — a total bucket of apparently up to $5 billion. Coincidentally, this is about how much is spent on mental health each year. And for this expenditure, we treat around 35% of the population requiring assistance, with the other 65% missing out on care.

The really big CoAG for mental health was in 2006. That delivered $4 billion worth of mental health-specific expenditure, the majority going to enable access to both clinical and registered psychologists under Medicare’s Better Access Program. The value of that investment is not yet clear but the depth of the commitment to addressing mental illness in Australia expressed at that CoAG meeting was irrefutable.

The $178 million allocated this time doesn’t really stack up by comparison and even then, some of the money announced is not new.

Thirteen million for more mental health nurses goes some way to redressing the funding taken from this program in the last budget. The commitments made to continue to invest in the community mental health programs largely run out of the Department of Families, Housing, Community Services and Indigenous Affairs are welcome but not ‘new’ as such. And as with Better Access, we can’t yet tell if these programs are really helping people yet. So much for evidence-based funding and policy with regards to mental health.

Seventy eight million for additional Headspace services builds on existing investments and offers $3900 per client — younger people with often complex and comorbid conditions. The $25m for the EPPIC early psychosis service is about one tenth of what was sought by its proponents.

The package also offered $57 million to develop tailored packages of care for 25,000 Australians with severe mental illness. Leaving aside that this amounts to $2280 per person, the exact nature of what model of care this expenditure seeks to advance eludes me.

In fact the whole model of mental health care is now more than ever, a hotch potch of governments, networks, primary care organisations, NGOs, private sector providers and probably others.  Working through this maze is tough if you are mentally well and not looking for any assistance. God help you if you are unwell.

A carer I spoke to yesterday described the mental health system as “mystical”, with rumours of service here and there, and the off chance that you and your daughter with schizophrenia might accidentally bump into care.  The Australian community deserves and demands better than this. This is not a situation that would be tolerated in cancer.

The only ‘big ticket’ item in CoAG with regards to mental health is sub-acute beds with some $1.6 billion in new beds to be shared between the mentally ill, palliative care, rehabilitation etc.  Sub-acute care, or step up-step down care as it is sometimes called is an attractive prospect. There has been admittedly little research into its outcomes, but there are a few such services operating in Australia now.

The overall key message from these services is that the critical element which makes mental health step up-step down services work is ensuring the balance between step-up and step-down.  In other words, these services cannot act as a dump, a place where acute ward bed managers can send people to clear a bed for someone even sicker. Sub-acute mental health care must offer the real chance for people who are becoming unwell to also access care from the community, obviating the requirement of often traumatic acute hospitalisation.  If step-up care is subsumed into step-down, then this model of care will be fatally compromised.

The actual share of this new spending to be provided to mental health is unclear. Also unclear is any commitment to fund the range of community services required to keep people living well once they are discharged from care, be it acute or sub-acute. The focus on bed-based solutions to mental illness still avoids investment in early intervention and prevention.  You should be able to seek and receive early intervention in the onset of your mental illness regardless of your age.

Perhaps the last and most interesting aspect of the CoAG announcement yesterday was the commitment to establish a National Performance Authority. This could, of course, have been done at any time by the Commonwealth and would have been strongly supported by the mental health sector which is bereft of any real measures of accountability.

It is strongly supported now and a dedicated and funded resource to establish mental health-specific national measures of system performance is now critical.  Such measures would consider the broader elements of mental health care, such as housing, community support and participation, employment and so on. Yesterday’s announcements with regards to mental health made no such links.

Mental health is often portrayed as the Cinderella service, left behind while the CoAG ball goes on. Yesterday’s CoAG outcome for mental health reinforced that impression. Still, perhaps no other health sector is better placed to appreciate the theatre of the absurd.

Sebastian Rosenberg is Senior Lecturer, Mental Health Policy at the Brain and Mind Research Unit, University of Sydney and a member of the Preventative and Community Health Committee of the National Health and Medical Research Council.