Two reports for the price of one: the royal commission numbers game shows there is still work to do

The final report from The Royal Commission into Aged Care Quality and Safety was released today, and after two years it looks like this could only be the halfway point on the way to transforming the sector.

Titled Care, Dignity and Respect, the report has been a long time coming. Established way back on 8 October 2018, the commission was extended once due to the scale of the task at hand and then again due to the impact of COVID-19.

It has been a commission of significant numbers – 125 weeks of harrowing, horrible testimony; or 2 years, 4 months and 24 days. It lasted 745 days from the first hearing to the last.

There were 23 public hearings and 20 research papers, 10,574 submissions, 641 witnesses were heard and there were 6800 telephone calls made to the commission's information line. 

There has been one interim report and one special COVID-19 report, put together by three royal commissioners, but finally, as these numbers have boiled and blipped away slowly for the last two years, we are left with a thick royal commission report – five volumes and 2,828-pages long and containing 148 recommendations for a way to finally fix this mess. 

The recommendations include a new aged care act, which enshrines the rights of older people and provides a universal entitlement for high quality and safe care based on assessed need.

The commission also suggests that a new governing body that is "independent of Ministerial direction" be implemented. An independent, dedicated statutory body should be established as system governor, administrator and regulator, called the Australian Aged Care Commission, the report says.

A new role of 'Inspector-General of Aged Care' is also recommended. This independent role will be to identify and investigate systemic issues in the provision or regulation of aged care, to make and publish reports of its findings, and to make recommendations to the System Governor and the Minister.

Workforce recommendations include increasing award wages for aged care workers and professionalising the aged care workforce through changes to education, training, labour conditions and career progression.

It is also recommended that personal care workers be subject to registration which includes a mandatory minimum qualification of a Certificate III and criminal history screening.

Minimum staff time should be standard for residential care, with registered nurses, enrolled nurses and personal care workers for each resident, and at least one registered nurse on site at all times.

The commissioners also want the current home care package wait list cleared by the end of the year, and to keep it clear by allocating a home care package at the approved level to any new entrants to the waiting list within one month of their assessment.

Two for one deal

Another quirk of this particular numbers game is that the government essentially got two reports for the price of one.

"The extent of substandard care in Australia’s aged care system reflects both poor quality on the part of some aged care providers and fundamental systemic flaws with the way the Australian aged care system is designed and governed. People receiving aged care deserve better. The Australian community is entitled to expect better," the commissioners said of the report.

They agreed that for too long the focus has been on the funding of providers and not on the needs of older people. Care must be safe and must assist older people to live an active, self-determined and meaningful life in a safe and caring environment that allows for dignified living in old age.

But there were many areas where they disagreed, and the report is divided into two sets of recommendations in many cases.

"Many of our recommendations and observations are made jointly, but there are some instances where we make differing recommendations and observations. We have agreed, with some misgivings and not without anxious consideration, to make some separate recommendations and to express different views where we diverge. But we both strongly conclude that fundamental change is needed. In the end, the differences between us may add to the strength of the reforms which are to be made," said chair of the Royal Commission, commissioner Tony Pagone, in his preface.

This divergence of opinion was hinted at during the final hearing late last year when commissioner Briggs appeared to attack the recommendations of the counsels assisting midway through the hearing.

It was a rare insight into the thoughts of the commissioner, made more revealing when commissioner Pagone disagreed with his colleague, appearing to walk back her comments.

“Mr Gray obviously those remarks are not intended to be a final decision by us,” he said at the time.

“They indicate that there are different views about how one may go about the system … and of course we would welcome different views. I suspect that my own view is much closer aligned to that which you have put forward and I don’t think that the description of them as ‘courageous’ is quite the right description.”

It is too early to know how this divided report might affect the process of instituting sector-wide change, but it's a fair guess that it won't make the government's decisions any easier.

"It's real," Prime Minister Scott Morrison said when asked about the disagreement between commissioners. The report is complex, much like the problem and the world, he said.

"We will work with the sector. The fact the commissioners have come to different views I think highlights the complexity of this problem."

Discussion will now continue about how much money is enough to fund the sector, how long should it take, and much more. But the most important number when discussing aged care is impossible to calculate. The innumerable residents, victims, families and friends that have been impacted by what has been described as "a cruel and harmful system" should never be forgotten as we try and forge a safer future.

At his press conference this morning, Morrison said that "he is committed to dealing with the issues that will test all of us," but the royal commission has provided a very important roadmap, which will help establish generational change. 

Perhaps now, with this report in hand, aged care and the people in it will finally be more than just numbers on a page.

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