More trouble ahead? The looming dispute over the Support at Home Program – opinion

A number of reports and planning documents released without fanfare by the Commonwealth Department of Health in January and February this year spell out the direction that the Federal Government seeks to take the proposed new Support at Home (SAH) program.

Scheduled to begin operation in mid-2023, the plans spell out some of the crucial details of a scheme that would radically change the existing system of community-based and home care in this country, converting it to something that seems to closely resemble the NDIS.

But the department’s plans for the SAH do not look like they will receive the smooth ride that the senior public servants responsible for their implementation seem to think. They are facing scrutiny and criticism, with opposition led by a number of senior industry figures and alliances.

Foremost among the other voices is the Support at Home Alliance, which includes ACSA, the Ethnic Communities’ Council of NSW and a range of more specialised peak organisations from the CHSP, including Community Transport (NSW), Home Modifications Australia, Meals on Wheels Australia and the NSW Neighbour Aid & Social Support Association.

Their campaign is a national one, with detailed arguments set out in a discussion paper released in December 2021 entitled Seamless Aged Care: How to set up ‘SUPPORT AT HOME’ Right, the first time. It certainly raises some very fundamental concerns about the Federal Government’s plans which have national implications.

The central idea behind the SAH program is that of reducing complexity by integrating a number of existing programs into a single, much larger one. Hence, from July next year it is proposed that the Commonwealth Home Support Programme (CHSP) will be amalgamated with the Home Care Packages (HCP) Program and the (little known) Short Term Restorative Care (STRC) Programme to form the SAH Program.

It will certainly help overcome the spelling inconsistencies that have crept into our programs. Or is that programmes? Gone, too, is that sensitive word ‘care’. It will now be replaced by the less intense and personal form of assistance referred to as ‘support’. As those skilled in manipulating them will confirm, words matter. So too does funding, eligibility and entitlement categories.

The SAH plans are to replace the complexity of the existing funding schemes for the CHSP, based on ending annual block funding grants, despite the clear call from the Royal Commission to continue this form of broad investment in service development. Similarly, the four levels of funding for home care packages are to be abolished, replaced by what sounds like a single mechanism – the ‘point-of-delivery payment’. This is what we all know in health care as the fee-for-service system.

Before it is destroyed, it is worth stopping for a moment to think about the relative merits of what is being replaced. The CHSP operates as a block-funded system of support, paid for by Federal and State governments to provide an alternative to reliance on institutional facilities. It provides basic home support services such as prepared meals, day care, home nursing, community transport, as well as social and home support which may include cleaning, showering, help with dressing and so on. It supports over 800,000 people annually: by far the largest number of them being aged care consumers. Importantly, this care can keep people more active and independent and defer the time when they may have to go into residential care. Yet its costs are low: just under $70 for each consumer per week, according the data released in 2021 by ACFA.

Home Care Packages, provided to a much smaller group, cost $387 per week on average. Both forms of support, it should be added, are far less costly than residential care, which comes in above $1,000 per week per recipient. Looking at these figures, the question needs to be asked, why would anyone seek to abolish such an effective and efficient program as the CHSP?

For the department’s advocates, the amalgamation of the two programs and their common adoption of fee-for-service funding is all presented as a done deal. It has not been tested in practice. Nor has any modelling of the potential explosive rise in costs been released. Yet if we look at the costs for the NDIS, it seems likely that costs per individual will rise.

To manage this those with lower levels of support may miss out, as happens in the disability field. Similarly, the approach would damage prospects for developing a more professional and secure workforce employment system. The SAH Alliance rejects the fee-for service model and calls for a common approach to payments across the aged care field. Its scheme would be similar to the new funding system being introduced for residential aged care, the Australian National Aged Care Classification (AN-ACC). This, they argue, would be able to respond to a mix of both ongoing (fixed costs) and episodic (or variable) service interventions, and would combine some of the clear benefits of the existing block funding provided to the CHSP, and the flexibility of case-mix funding.

The new program and the proposals for regulation seem to have a low profile at present. It has been presented as a modernisation of regulation that would enable the SAH program to operate like the NDIS. But there are many who argue that such a system would undermine care standards entirely, and promote the development of insecure employment based on the labour system evident in the US – hardly the model of professional career focused workforce called for by the Royal Commission.

But if the SAH Alliance and others concerned about the future of aged care at home have their way, the future of aged care in Australia is not yet a foregone conclusion. Before we destroy the social capital built up over the past 40 years through the largely non-profit CHSP system, there is still time to get it right. And there is a federal election.

Michael Fine is honorary professor in the School of Social Sciences at Macquarie University.

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