“Square peg, round hole”: Why program design makes CHSP-Support at Home merger impossible

Professor Kathy Eagar, a leading expert in aged care funding and policy, has delivered a scathing critique of the federal government’s plan to transition the Commonwealth Home Support Program (CHSP) into the Support at Home program, branding the move as fundamentally flawed at its core.

Appearing via video link before the Senate Community Affairs References Committee last week, Professor Eagar did not mince her words. She opened by rejecting the very premise of the inquiry.

“The terms of reference presuppose that this is a done deal and that the inquiry should be looking at how this is going to work and what the consequences might be,” she said. “I really feel that it’s such a bad decision, and I know the government doesn’t want to make a bad decision, that I want to start by saying I don’t support the transition.”

At the heart of her opposition lies a basic principle of program design: incompatibility between two fundamentally different funding models. CHSP operates as a grant-funded program, delivering efficient, entry-level supports such as meals, transport and social activities through block-like allocations to providers. Support at Home, by contrast, is an individualised funding program where each person receives an assessed quantum of funding, triggering a cascade of assessment, compliance and business rules.

“There’s a first rule of program design here that says you can’t integrate a square peg in a round hole,” Professor Eagar told the committee. “These are incompatible ideas; they don’t meld together as one program, other than if you wanted to just change the name of one.”

She elaborated that Support at Home, by definition, allocates a fixed quantum of funding per individual after assessment, with all subsequent rules flowing from that. CHSP, however, uses grant funding to support providers in delivering services flexibly to meet community needs without the same level of individual prescription.

“Essentially, when I read through the submissions, I find you’ve got three types of submissions,” she said. “The first are people like me who just say, ‘Don’t do it.’ The second group of people say, ‘Call it integration, integrate the two but keep grant funding for CHSP,’ which is a very polite way of saying, ‘Don’t do it.’ The third group of submissions are saying, ‘Integrate the two, keep block funding, and don’t do it until Support at Home is working well,’ which puts it off onto the long finger.”

Professor Eagar stressed that this is not mere semantics or a minor administrative tweak.

“This is not just about changing the name and putting two things together that don’t fit,” she warned. “I know some people have suggested calling it all ‘Support at Home’, but consumers are already highly confused. Changing the name and calling two different ways of receiving services the same thing would just add to the confusion.”

The expert, who advised behind the scenes during the Royal Commission into Aged Care Quality and Safety and designed the AN-ACC funding model for residential care, pointed out that the government’s approach misinterprets the Royal Commission’s recommendations.

“The royal commission recommendation has been reinvented in history,” she said. “I was an adviser, as you know, behind the scenes at the royal commission. The royal commission recommendation was for one program that included residential care packages, respite et cetera, and the rest of it has been lost. They didn’t mean one program in the way that’s now developed.”

She argued that the selective focus on merging just CHSP and Support at Home ignores the broader vision of a coherent aged care system.

“Even if Support at Home were working well, and it certainly isn’t, but even if it were, I would not support this proceeding,” Professor Eagar stated. “We really do need a primary care, accessible way for people to access the system and move across it.”

Drawing parallels to other government programs, she highlighted inconsistencies in policy direction. The government invests heavily in primary health care, with bulk-billing for GPs and urgent care centres, to prevent higher costs in hospitals. Yet in aged care, it risks dismantling the equivalent primary tier.

“It doesn’t make sense to make fees for the primary care level of the aged care system prohibitively expensive,” she said. “The government understands this in primary health care. It’s got a massive commitment. We’re very welcoming of it. GPs can be bulk-billed 90 per cent of the time and there’s been a major investment in urgent care. The government’s not just doing that because people are nice. They’re doing it because they want to prevent costs upstream in more expensive secondary and tertiary care.”

Professor Eagar proposed CHSP should be revitalised as the primary care tier of aged care, with “no wrong door” entry points. People could access services via GPs, hospitals or directly through providers like Meals on Wheels, without funnelling everyone through a single, overspecified gateway that creates massive queues.

“We should be looking at a model for a primary care level of aged care which is based not on one gateway but on ‘no wrong door’,” she explained. “People should be able to easily enter the aged care system through ‘no wrong door’, that is, via a referral from a GP or a hospital. If somebody walks into the Meals on Wheels office and says, ‘My mum needs Meals on Wheels,’ that should be the door, rather than forcing everybody onto a queue that already has 200,000 or 300,000 people on it.”

She criticised the current assessment regime as “wildly overspecified” and expensive, noting billions are spent on assessments without delivering services.

“We’re now spending a couple of billion dollars assessing people without giving them services,” Professor Eagar said.

On funding, she advocated a hybrid model over pure block grants, which she described as “set and forget”, leading to neglect.

“I don’t support block funding, but I support grant funding, and the difference is important,” she told Senator Cox. Her suggested approach mirrors aspects of AN-ACC: a base component for fixed costs, plus price and volume contracts that allow budgets to grow with demand within tolerance bands.

Professor Eagar also touched on the human and operational fallout from prolonged uncertainty. CHSP has operated on 12-month funding cycles, eroding job security for sector support staff and preventing long-term investments.

“Sector support has been put on 12-month, year-to-year funding now,” she noted. “This is not the way to attract and retain the people who have such good expertise that they can build capacity in this sector. That is an urgent issue. We cannot expect sector support and development teams across the country to keep going when they’ve literally all got mortgages to pay, like everybody else.”

She warned that indecision is unethical.

“There are 850,000 people in this program, and many of them are extremely anxious about what’s going to happen to them,” Professor Eagar said. “The staff in CHSP deserve to know what’s going to happen to them. Over the last decade CHSP has been the one part of the aged care system that has not had problems attracting and retaining its workforce, but I’m starting to hear that those problems are emerging because of job insecurity. I don’t think it’s okay for everybody to go into inertia about CHSP. It’s had 10 years of neglect, and neglecting it even further, in my view, is actually unethical.”

Echoing lessons from the NDIS, she cautioned against making Support at Home the “only ship in the ocean”.

“We’ve got this real inconsistency now across government that needs to be reconciled,” she said. “We’ve got a major investment hoping, optimistically, that we improve rates of bulk-billing and easy access to primary health care. We’ve got the government recognising that the individualised funding model in NDIS is unsustainable. Then, in aged care, we’ve forgotten both of those lessons and we’re trying to actually now create an individualised fee-for-service model at the same time as both of those other programs are trying to reduce that and go back.”

Professor Eagar’s evidence underscores a broader critique: the government’s aged care reforms risk prioritising administrative uniformity over effective, cost-efficient prevention. With baby boomers approaching peak old age and a projected 60 per cent increase in those aged 80 and over within a decade, dismantling CHSP’s efficient model could drive unsustainable demand into higher-cost tiers.

Her seven reasons for opposing the transition, detailed in her submission, and five alternative recommendations centre on preserving and enhancing CHSP as a distinct, prevention-focused program.

“My alternative recommendation is that CHSP should have a major investment and be further developed as the primary care tier of the aged care system,” she concluded in her opening statement. “Just as it makes no sense to think about the idea of abolishing GPs to save money in the health system, abolishing CHSP, the prevention and early intervention arm of aged care, also makes no sense.”