Royal Commission into Aged Care shows the difficulty of systemic change must be overcome

Since his unlikely victory at the polls in 2019, his prime ministership has been one damn thing after another - bushfires, Covid, predatory ministerial staffers and compromised ministers, vaccine issues - and underlying it all, and exacerbated by the pandemic, the continuing problems in aged care. The Royal Commission into Aged Care Quality and Safety, which reported in March this year, did not tell us much that was new, but it gave his government plenty to work with.

While the PM's ear for personal values sometimes lets him down, he knows a political issue when he sees one. There are votes in them thar old folks, and their families, too. The government has already announced a funding package of $452 million to address priority issues, and is widely expected to do more when the budget is delivered next week.

Whether that 'more' will actually make a difference to the quality of life of older Australians is, however, a moot point. The Royal Commission made 148 recommendations, each containing multiple components, covering every aspect of a system widely considered to be failing. At the heart of the recommendations, though, lies a commitment to institutional reform based on top-down bureaucratic control and monitoring. The system, the implicit argument goes, will work better if there is more pressure on providers to perform. There are real dangers in this approach.

Part of the difficulty results from a stereotyping of the policy process. While Royal Commissions are excellent at focusing attention on issues that have become in some respects intolerable, building the solution around what everyone thinks is the problem is, from a policy point of view, unlikely to prove satisfactory. This is because Royal Commissions rarely have the time or the analytical horsepower to move beyond the outrage that led to their establishment in the first place, and to understand why and how the system is falling short.

The Royal Commission into Aged Care is no exception to this general tendency. Its job was made even more difficult by the fact that the two Royal Commissioners found it difficult to agree on the extent to which care really was substandard. Commissioner Briggs thought the extent of the problem had been clearly established. Commissioner Pagone was not so sure. There were further disagreements about the style and substance of reform. Commissioner Briggs clearly thought the providers needed the firm hand of the Commonwealth to ensure that the right things were done. Commissioner Pagone called for a more evolutionary approach.

What seems to be missing from the recommendations as a whole is in any real focus on what older Australians told the Commission is the key issue: they want to be able to retain their independence as we age. This has implications for the policy response. It is possible to retain one's independence in one's own home and in a retirement village. It becomes much more difficult when you are institutionalised. Residential aged care is clearly needed for those who can no longer manage on their own, even with help. But for all of us, the context within which care is provided is as important as the care itself.

Research commissioned by the Royal Commission reports one rather surprising statistic. Australia has one of the highest rates of institutionalisation of its citizens over the age of 80 of any country in the world. Even allowing for differing measurement techniques, there is no denying it. For a variety of reasons, more older Australians are placed in residential aged care than their counterparts in other comparable countries.

Given this predominance, the Commission's focus on managing residential aged care is understandable. Some providers and some facilities are clearly substandard. But if, as a society we are relying more on residential aged care than should be the case, even improved facilities of this kind will not lead to better outcomes. The underlying problem appears to be much broader: there are not enough ways for older Australians to receive services while also engaging meaningfully with the society around them.

The language of rights is not helpful here. It is good to know I have a right to be treated with respect as I age. But being well-treated does not necessarily help me to be heard. And as we age we all want to be part of something meaningful. Heaven forbid that we end up in an ABC documentary with four-year-olds or (even worse) subjected to a wellness regime based on prescribed pets. But it is the opportunity for connection that counts.

The Royal Commission focused on improving the quality of what is done for and to older Australians. In the next phase of the debate, we should be talking about local areas and communities, and how, through them, we can maintain both independence and connection as we age.

If the goal is independent living, more choices are needed. An obvious priority would be the provision of more affordable alternatives between the family home and the nursing home. Well-serviced retirement villages have considerable potential in this regard, but may not be available or accessible to consumers.

As for connection, let's hear from those who know ageing from the inside - those who are going though it, and organisations with a long history in the field - as to how this might best be achieved.