Five years after the Royal Commission on Quality and Safety in Aged Care reported, its legacy offers hard-earned lessons about reform, funding, implementation and the limits of inquiry-led change.

The Royal Commission on Quality and Safety in Aged Care reported in February 2021. Experience over the five years since provides 10 lessons not only for aged care but for those who call for a Royal Commission into every concern that arises – not just those of serious national importance.

The Aged Care Royal Commission was called more than a year after investigations failed to resolve issues of poor quality care at Oakden nursing home in Adelaide and revelations of breaches in standards in other aged care services.

In their final report, Commissioners Briggs and Pagone made 148 recommendations. The Morrison Government’s response in May 2021 saw the great majority, 107, ‘accepted in full’, 19 ‘accepted-in-principle’, 11 ‘subject to further consideration’, and ‘support instead’ in four cases where the Commissioners made alternative recommendations. Seven were ‘not accepted.’ This response teaches Lesson 1: Recommendations of a Royal Commission are just that, recommendations: they are not binding on government.

On coming to office in May 2022, the Labor Government largely followed these responses and acting on Recommendation 12, appointed an independent Inspector General of Aged Care. In May 2025, the IGAC tallied 13 recommendations as ‘finalised’, 54 ‘substantially progressed’, and 53 ‘commenced but only partially progressed’. Ten had ‘not been commenced,’ including the seven ‘not accepted.’ Even when some actions since then are taken into account, Lesson 2 is: Implementation of Royal Commission recommendations can be uneven and slow.

The scope of the 20 matters set out in the Commission’s Letters Patent spanned the whole aged care system. But recommendations setting out significant new directions were outnumbered by others that essentially geared up existing policies, programs and processes. Without synergies to generate cumulative change, Lesson 3 is: Royal Commissions that aim to tackle everything, everywhere, all at once, risk spreading effort too thinly to drive systematic change.

Despite its breadth, the Royal Commission had some gaps, notably the absence of any mention of Carer Allowance and Carer Payment in discussions of informal carers. When introduced as the Domiciliary Nursing Care Benefit in 1974, Carer Allowance was equal to the ‘ordinary care’ nursing home benefit. This parity was not indexed and at $81.30 per week it is now just 5.5 per cent of the lowest care category in residential care. The missed opportunity for an increase in Carer Allowance could yet be made good through the Commonwealth Budget. In the meantime, Lesson 4 is: Even a comprehensive Royal Commission can miss opportunities for straightforward and significant change.

One recommendation for major change, Recommendation 25, proposed bringing residential care and community care together in a single program under the new Aged Care Act 2024. It was ‘accepted-in-principle,’ but with little action taken, the IGAC re-assessed it as ‘rejected in favour of an alternative approach.’

The modified goal of combining the Commonwealth Home Care Program with the Support at Home Program now has a timeline of over six years, not to start before mid-2027. This compares badly with ‘generational change’ in the early 1980s that unified four programs operating under different Acts, each funded on a different Commonwealth-State cost-shared basis. It was just over three years from the recommendation made by the House of Representatives Standing Committee on Expenditure in October 1982 until the Home and Community Care Act was passed in December 1985 and funding commenced in the 1986-87 budget.

This failure in community care is a key part of the IGAC’s conclusion that the transformative change envisaged by the Royal Commission has not been realised. In making a clarion call for an urgent change in approach, the IGAC pointed out that implementation of separate measures has failed to realise ‘collective’ outcomes. The appropriate Lesson 5 is: In order to take a great leap forward, a Royal Commission has to set out milestones for the long march.

It is hardly surprising that the seven ‘not accepted’ recommendations all concerned financing. Major funding reform underpinned two transformations: Recommendation 1 included a universal entitlement to care, and Recommendation 125 called for abolition of user charges. Both Commissioners proposed the introduction of an aged care levy as the means to covering future aged care cost, Briggs a 1 per cent Medicare-style Aged Care Improvement Levy and Pagone a hypothecated levy. Neither was satisfactory, but a response of ‘referred for further consideration’ rather than ‘rejected’ would have kept this critical debate alive.

Instead, a Taskforce on Aged Care Financing was set up and co-chaired by then Minister Anika Wells. Adoption of the measures it proposed has seen a complicated schedule of increased user charges implemented from November 2025, demonstrating Lesson 6: Not only does government not have to adopt and implement the recommendations of a Royal Commission, it can do exactly the opposite.

One recommendation that did involve substantial Commonwealth expenditure was Recommendation 84: Increases in award wages. Whereas the Morrison Government only ‘noted’ that this matter was before the Fair Work Commission, the Albanese Government supported the claims made by the Health Services Union. The decision of the FWC to award increases in the order of 25 per cent over two years provides Lesson 7: A Royal Commission is not the only way to bring about significant change; other agencies play supporting (or opposing) roles.

Generating revenue from user payments depends on services being provided. Despite their protestations that the needs-based planning system restricted supply of residential care places, providers have not rushed to invest since its removal. The shortfall in beds that has emerged may be difficult to overcome in the face of the burgeoning very old population over the next decade. Past experience that development is constrained by uncertainty and the evaporation of confidence in the much vaunted demand-driven market present Lesson 8: Royal Commissions should listen to what the stakeholders say, but also watch what they do.

The Aged Care Royal Commission did not exercise its powers to summons witnesses or compel them to give evidence on cases of abuse or financial irregularities. It did not call for or lead to any criminal penalties. The protracted reform process is far from complete, with further reviews, two Senate inquiries concluded and two currently underway, suggesting Lesson 9: If exercise of a Royal Commission’s special powers is deemed unlikely, it may not be the only or best way to proceed.

The new charging regime has been in effect for only a few months, but advocates are already hearing of problems. More importantly, so are local members, and a large parliamentary majority necessarily includes many with narrow margins who are prone to become nervous in such circumstances.

Vociferous complaints about the proposed ‘bonds’ for nursing homes ahead of a South Australian election in late 1997 were channelled through local members to PM John Howard. In a late night phone call, he ordered the senior bureaucrat charged with implementing the scheme to ‘drop the bonds.’ Howard told the Nine Network: “I think we’ve made a mistake with the implementation of this. Governments from time to time make mistakes, and when they do, what they ought to do is recognise it and do something about it.”

Lesson 10 echoes George Santayana’s words from 1905: Those who cannot remember the past are condemned to repeat it.

Or as Bruce Petty had it in his cartoon in The Age, a craggy character sitting in the nursing home day room asked another in the next chair ‘What’s it called when you can’t remember what you’re meant to be doing?’ The reply: ‘Government policy.’