Over the past two years, a Royal Commission into aged care quality and safety has heard the harrowing evidence of a broken system. It’s a system that supports 1.3 million Australians, their families and friends and the 400,000 people who work in the sector. In this episode of Squiz Shortcuts, we take a look at the system itself, why a Royal Commission was called and its findings, and where things go from here.

Let’s get our bearings… What makes up our current aged care system?
Our Shortcut on Aged Care goes into the nitty-gritty but in short, it’s the responsibility of the federal government which is tasked with funding, accrediting and regulating the sector. It caters for Australians aged 65 and over, and Indigenous Australians aged 50 and over – who can no longer live without support in their home. The sector employs more than 360,000 people and cares for more than 1.3 million Australians.

The system includes both residential care and home care, with the vast majority of people accessing the system getting varying levels of home care support. While most people receiving care in residential facilities are older Australians, there are also around 6,000 young people in aged care facilities around the country.

How is the system funded?
The Australian government funds the majority of aged care by supporting service providers through a mix of subsidies and supplements, capital grants and program funding. But, Australians who received government-subsidised aged care also make contributions if they can afford to. In 2019-20 the feds spent $21.2 billion on aged care – most of which was on residential care.

How is it overseen?
The Department of Health largely oversees residential aged care, including capital grants to providers and developing policy for residential aged care. It also runs the Aged Care Quality and Safety Commission which checks whether or not providers are meeting quality standards. But both the Health Department and Commission have been criticised for not doing enough to uphold standards in aged care facilities.

What are some problems that have been identified in the current system?
Like many developed countries, Australians are living longer than ever before, and the number is only going to get larger over time. As pressure builds on the system, the problems around care are only set to get worse. Across the country, a number of elderly Australians and their families, as well as aged care staff and providers, have spoken up about the sub-standard care with complaints ranging from understaffing, mistreatment, physical and sexual abuse, poor dietary standards, over-medication, neglect and preventable deaths.

So how does Australia’s aged care system stack up to those of other OECD countries?
When it comes to funding, we’re lagging behind. Research by Flinders University found that Australia’s spending on long term aged care was among the lowest when compared to 13 other OECD countries, and that’s despite having the highest proportion of older people living in institutional care. It also found that institutional care, compared to home or community care, was the highest in Australia compared to those other nations.

What kicked off the Royal Commission into Aged Care Quality and Safety?
Concerns around Australia’s aged care sector are not new, but there have been a few big moments that have brought the issues to the widers public’s attention. Reports of sexual and physical assault and the overmedication of residents in Adelaide’s Oakden aged care facility – that was operated by the South Australian government – saw it close in 2017. A state inquiry also uncovered several allegations of mistreatment at another Adelaide nursing home. Then Melbourne’s Allambee Nursing Home was likened to Guantanamo Bay, and an aged care worker was convicted for assaulting an elderly man at a facility on Sydney’s northern beaches in 2018.

And then newly-minted PM Scott Morrison called the Royal Commission?
That’s right. The announcement by Morrison in 2018, who had only been in the job for three weeks, came on the eve of a highly anticipated ABC Four Corners investigation into abuse in nursing homes. Launching the inquiry, Morrison said “if you want to deal with a problem, you have to be fair dinkum about understanding the full extent of it.” He had support by then Labor leader Bill Shorten for that move.

Remind me what a Royal Commission is again?
It’s a way to hold people accountable for doing the wrong thing, and create a plan – or recommendations – to prevent future wrong-doings.

So what did it find?
The interim report, titled Neglect, was released at the end of 2019 and made some really harrowing and devastating revelations. One particularly horrible piece of evidence was delivered by the counsel assisting the inquiry Peter Rozen, who said an estimated 50 sexual assaults occur each week in aged care homes. He described the Commonwealth, at the time, as “missing in action”. The report also stated residents were left lying in their own waste, wounds were inadequately treated, there were serious issues around poor food leading to malnourishment and evidence of the widespread use of chemical restraints – that is, residents being drugged to keep them placid and easier to manage.

What about those not in residential care?
The inquiry also said about 16,000 older Aussies died while on the waiting list for support through the home care system because there simply wasn’t enough funding. And there are around 6,000 young people who had no choice but to spend their lives in an aged care facility. On top of that we were also told that according to research conducted for the Royal Commission, the system needed a $621 million a year boost to get all Australian aged care homes to meet basic standards. And for $3.2 billion a year, the sector could be brought up to a standard of care considered to be above average.

What did it say about the system during the COVID-19 pandemic?
The commission released a separate report about how the COVID-19 pandemic has exposed cracks in the system, saying the aged care sector was not adequately prepared to deal with a disease like coronavirus and that federal agencies had “no plan” on how to contain it in the sector. At least 685 aged care residents have died from the virus, accounting for 65% of people who have died in Australia from coronavirus since the start of the pandemic. And most of those cases and deaths occured in Victoria during the second wave. When asked last year if these deaths could have been avoidable, the now Health Department Secretary Brendan Murphy said the spread of COVID-19 could have been minimised if action had been taken earlier.

So how did the federal government respond to the Commission’s findings?
To address some of the problem areas outlined in the Royal Commission’s interim report, the Morrison government announced a $537 million package on aged care. The majority of those funds went to 10,000 home care packages, with the rest spent on improving medication management, training around dementia patients and measures to remove young people who live in aged care.

What new findings were revealed in the Commission’s final report?
Titled Care, Dignity and Respect, the final report from the Royal Commission concluded that at least a third of people accessing residential aged care and home services had experienced substandard care and half of them worry about the qualifications and commitment of those in charge of caring for them. It also outlined 148 wide-ranging recommendations that Commissioners say will take five years to implement to help older Aussies.

What were those recommendations?
They included approving home care packages within one month, clearing the waitlist by the end of the year, ensuring a registered nurse is always on duty in an aged care home and that no person under 45 years is in aged care from January next year. It also recommends that only psychiatrists or geriatricians determine the prescription of antipsychotic drugs, in a bid to restrict their use in residential aged care. The Commissioners have also called for all staff in aged care to have a minimum level of training in line with the childcare sector, as well as for the Aged Care Act to be replaced to put the rights of those in the system at the heart of things.

But there were some disagreements about how to go about fixing things…
That’s right. What’s gaining a lot of attention is the fact that the commissioners aren’t on the same page on about a third of issues raised, particularly on funding models and governance issues. The PM said that was a result of “the complexity of this problem”. For instance Commissioner Tony Pagone wants a new independent body to replace the existing federal government regulator, while Commissioner Lynelle Briggs feared a new body would lead to further dysfunction.

They did agree on some stuff though…
They did – both agree that a complete overhaul of the aged care system is required. And PM Morrison agrees with that.

So what’s the response been from the federal government?
As we covered earlier, the Royal Commission has heard evidence that about $4 billion in funding is needed to bring standards up to scratch. But what the recommendations in the report is far beyond that and with PM Scott Morrison saying the government will look at all of it and make policy and spending decisions that will start with the federal Budget in May.

One thing that hasn’t been ruled out is a Medicare-style levy that would see most Aussie taxpayers contribute to improving standards. He also announced the government will put $452.2 million towards some immediate priorities.

What did others have to say about that?
Labor’s Aged Care spokesperson Clare O’Neil said the PM’s response doesn’t fill her with much confidence. She said she’s concerned that this report will join the 21 other major reports done in recent times. Advocates including the Council on the Ageing are hopeful this process is the catalyst for change. Others were disheartened – and it’s understandable there’s some exhaustion there with the case for change so clearly understood.

Squiz recommends:

Life advice from the residents of Waratah Lodge

The ABC’s Four Corners two-part series Who Cares?