We've had 20 aged care reviews in 20 years – will the royal commission be any different?

Prime Minister Scott Morrison’s Royal Commission into Aged Care Quality and Safety is one of more than 20 such inquiries into aged care stemming back to 1997. This latest inquiry, announced on Sunday, will no doubt highlight the systemic problems that have been previously reported.

The Australian aged care sector is one of the most highly regulated complex care environments. It would be fair to say the sector has been working on establishing an optimal care model for the past two decades that is more consumer focused.

Older Australians and their families need to know the facility they have chosen will provide safe, high quality, person-centred care that is grounded in respect, comfort and dignity. However, as revealed on Four Corners on Monday night, this is not always the case. Many stories that were shared reflect wider systems failures, which have been highlighted in the numerous inquiries that have preceded this royal commission.

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What have previous reviews found?

The sector receives significant funding. In 2017, it received A$11.4 billion in government funding and generated A$21.5 billion in revenue, or A$263.92 per resident per day. It’s estimated care subsidies make up 70% of provider revenue.

The 2017, Aged Care Funding Instrument Review was prompted by the rapid growth in the aged care subsidy budget. Many residential aged care organisations continue to complain about the constraints on care funding that came about from this 2017 review, which limits their capacity to employ staff. Yet some of the 949 providers do manage to provide high quality care within the current funding envelope.

The bulk of care provided by Australia’s 366,000 aged care workers continues to be delivered by unskilled workers. These carers make up 75% of the workforce and have limited training. They are supervised by a small number of registered nurses.

This workforce structure belies the significant medical, nursing and social needs of older Australians living in residential aged care. These concerns were expressed during the senate inquiry held prior to the introduction of the 1997 Commonwealth Aged Care Act.

It was predicted that the removal of the registered nurse to resident ratio would lead to compromised care through deskilling and under-staffing, and that the accreditation process would do little to prevent this from occurring.

The sector has undergone significant reform since the 2011 Productivity Commission report Caring for Older Australians. In 2013, the “Living Longer Living Better” Act was introduced to address many of the recommendations in this report, including increased focus on consumer choice and control and additional funding to increase wages within the aged care sector.

In 2017, the Living Longer Living Better Act was also the subject of a review to assess progress of the first phase of reform and the pathway ahead.

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In 2012, a new review – Australian Skills Quality Authority: The training for aged and community care in Australia – identified a number of aged care workforce training gaps. Namely, that carer training programs were too short and there was insufficient time for supervised practical experience to foster skill development.

Registered training organisations delivering high-quality training programs also faced unfair competition from those offering cheap and unrealistically short training programs. A range of compliance issues were identified that had an adverse impact on carer capabilities.

Since then, the 2017 Review of National Aged Care Quality Regulatory Processes has highlighted the need to improve the quality of care and strengthen institutional governance. Meanwhile, the 2017 Aged Care Workforce Strategy Taskforce was convened to address these gaps and to boost workforce supply in residential aged care.

Will the royal commission be any different?

There is no shortage of reviews into aged care, and they all provide rich data to draw on. Royal commissions are good at enabling people’s stories to be heard and evaluated. They are also good at eliciting a broader body of evidence and gaining political and public attention.

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But recommendations from previous reviews into aged care have not always been acted on. This may be because they have been conducted to only look at one aspect of the sector, when in reality, aged care financing, regulation, quality of care and workforce planning are all necessary elements in providing high quality aged care.

It’s important this royal commission takes an in-depth examination of all elements underpinning quality care. It will also need to have the scope to make recommendations that go beyond changes to the regulation of safety and quality and the governance of the regulator.

The commission needs to be designed in such a way that consumer choice and control in aged care can be improved. Services need to meet individuals’ needs in a way that is affordable for consumers and sustainable for taxpayers.

And the commission’s terms of reference need to be carefully framed so the recommended reforms improve the quality of life and well-being of the 200,000 older Australians who currently live in residential aged care.