Policy analysis disclaimer: This article presents evidence-based analysis of Australian aged care policy and the Royal Commission into Aged Care Quality and Safety. It does not constitute legal or professional advice. All statistics cited reflect published government and research sources. Policy positions represent analysis by Coalition for Better Health contributors.
Introduction
In March 2021, Commissioners Tony Pagone and Lynelle Briggs released the Final Report of the Royal Commission into Aged Care Quality and Safety — a two-volume document that characterised Australia's aged care system as one delivering "substandard care" and constituting "a national disgrace." Established in 2018 following a series of serious incidents in residential facilities, the Royal Commission heard evidence from more than 10,000 sources over 18 months, producing 148 recommendations spanning regulation, workforce, funding, rights, and home care.
Five years after that report, the reform trajectory is mixed. Significant legislation has passed, and the 2021–22 Federal Budget committed $17.7 billion over five years in the largest single aged care investment in Australian history. But implementation has been uneven, monitoring remains inconsistent, and the structural conditions that produced the original crisis — understaffing, opacity, underfunding, and a culture of institutional convenience over individual dignity — have not been fully dismantled.
This article assesses where reform has succeeded, where critical gaps persist, and what completing the Royal Commission's vision requires in practical policy terms.
The Royal Commission Findings (2019–2021)
The Commission's mandate was sweeping: examine the quality of care provided to Australians in residential facilities and home care settings, identify system failures, and recommend reform. What emerged from the hearings was damning.
Commissioners Pagone and Briggs found evidence of:
- Substandard clinical care: Malnutrition was prevalent in residential facilities, with some studies cited in evidence finding rates exceeding 50% among residents in some facilities. Pressure injuries, medication errors, and preventable hospitalisations were recurring failures.
- Inadequate staffing: Direct care hours per resident were insufficient by international benchmarks. Registered nurses were frequently absent, with personal care workers — often with minimal formal training — left to manage complex clinical needs.
- Institutional abuse of older people: Incidents of physical, emotional, and financial abuse were documented, often unreported and unaddressed by providers or regulators.
- Structural underfunding: The Aged Care Funding Instrument (ACFI), then the primary residential funding model, was assessed as gameable, poorly linked to resident acuity, and incentivising documentation over care.
- Poor regulation: The regulatory framework under the 1997 Aged Care Act was assessed as inadequate — reactive, under-resourced, and lacking the enforcement powers to produce meaningful compliance.
On home care, the Commission found that 54% of home care recipients were waiting for an appropriate level of support, often languishing on wait lists for higher-level packages while receiving lower-level services that did not meet their assessed needs. Average wait times for a Level 4 Home Care Package at the peak of the crisis exceeded 12 months.
The Commission's reform blueprint included: a new rights-based aged care Act to replace the 1997 legislation; mandatory 24/7 registered nurse presence in residential care; minimum staffing ratios; independent regulation; pricing transparency; and a restructured home care system centred on consumer direction.
Government Response and Legislation
The legislative response to the Royal Commission has been substantial, even if not complete.
Aged Care and Other Legislation Amendment (Royal Commission Response No. 1 and 2) Acts 2021–2022 addressed immediate regulatory gaps, including expanded incident reporting obligations and strengthened Commission powers.
Aged Care Amendment (Implementing Care Reform) Act 2022 legislated the 24/7 registered nurse requirement for residential aged care, to take effect from 1 July 2023. This was one of the most contested recommendations; the sector lobbied extensively against it, citing workforce availability constraints, particularly in rural and regional areas.
Aged Care Act 2024 — the most structurally significant legislative reform — replaces the Aged Care Act 1997. It introduces a rights-based framework for the first time, anchored by a Statement of Rights for people receiving aged care. The Act reconceives aged care recipients as rights-holders rather than beneficiaries of a welfare system, which represents a genuine philosophical shift in how the law frames the relationship between older Australians and the services they receive.
Support at Home program, commencing July 2025, replaces both the Commonwealth Home Support Programme (CHSP) and the Home Care Packages (HCP) program with a unified, individually budgeted model across four funding categories. This reform aims to streamline access, reduce wait lists, and give recipients greater control over how their budgets are spent.
The 2021–22 Budget's $17.7 billion commitment over five years underpinned these reforms — a figure that reflected genuine political urgency following the Commission's findings, even if it has since been described by some analysts as still insufficient relative to unmet demand.
Progress Assessment: What Has Been Achieved
Against the scale of what was recommended, several genuine reforms are now embedded in the system.
The 24/7 registered nurse mandate has been largely implemented across residential aged care. Compliance monitoring remains an ongoing issue — particularly in smaller rural facilities — and some time-limited exemptions have applied in thin workforce markets. But the baseline requirement is now law, and facilities that cannot meet it face regulatory action.
The AN-ACC (Australian National Aged Care Classification) funding model replaced ACFI in October 2022. AN-ACC is clinically assessed through a standardised assessment tool and is substantially harder to game than its predecessor. Funding is linked to resident acuity rather than documentation outputs, which is a meaningful structural improvement.
The Star Ratings system, introduced in December 2022, provides publicly visible quality ratings for residential aged care providers across four domains: compliance, residents' experience, staffing, and quality measures. The system gives consumers, families, and the public a comparative tool that did not previously exist, and creates reputational pressure on under-performing providers.
The Serious Incident Response Scheme (SIRS), expanded in 2021 and strengthened subsequently, mandates that approved providers report certain incidents to the Aged Care Quality and Safety Commission. Reportable incidents include alleged, suspected, or witnessed abuse and neglect.
The Aged Care Quality and Safety Commission's enforcement powers have been expanded significantly — including the ability to issue banning orders, impose conditions on approved providers, and take civil penalty action. These are not cosmetic changes; enforcement actions have materially increased since 2021.
Remaining Gaps: What Is Still Inadequate
Despite this progress, five structural gaps remain that prevent the Royal Commission's vision from being realised in practice.
1. Staffing Ratios and Allied Health
Mandatory minimum care minutes — 200 minutes per resident per day, including 40 minutes of registered nurse time — took effect in October 2023. Compliance monitoring, however, has been inconsistent. The Australian Nursing and Midwifery Federation and the Royal Commission both identified allied health — physiotherapy, occupational therapy, speech pathology, dietetics — as critical to preventing clinical deterioration that produces unnecessary hospitalisations and poor quality-of-life outcomes. No allied health minimum has been mandated. Residents with complex musculoskeletal, nutritional, or cognitive needs are not guaranteed timely allied health input under the current framework.
2. Home Care Wait Lists
The Support at Home program aims to address the structural demand backlog in home care, but the transition period itself creates disruption risks. At various points during 2023 and 2024, more than 80,000 Australians were waiting for a higher-level home care package than they had been assessed as needing. Even with the unified budget model and expanded funding, the rate at which new entrants receive appropriate-level support depends on whether the budget envelope keeps pace with a rapidly ageing population. Early signals from sector peak bodies suggest that budget adequacy for the Support at Home model requires close parliamentary monitoring.
3. Dementia Care
Approximately 400,000 Australians currently live with dementia, and that figure is projected to approach 1.1 million by 2058 (Dementia Australia, 2024). Dementia is the second leading cause of death in Australia and the leading cause among women. Yet dementia-specialist training in the aged care workforce remains inadequate and inconsistent. The Dementia Support Program — jointly funded and administered across Commonwealth programs — provides behavioural support through dementia support specialists, but reach is constrained relative to the prevalence of the condition in residential and home care settings. A National Dementia Strategy with legislated workforce training minimums is absent from the current reform architecture. This is an omission the Royal Commission explicitly flagged.
4. Rural and Remote Access
Provider viability in thin geographic markets remains a critical structural problem. Fee-for-service funding models do not adequately account for the fixed costs of operating in areas with small populations and significant distances. Fly-in/fly-out clinical models have been deployed in some settings but are inherently fragile. Indigenous aged care settings — where the intersection of health inequality, geographic remoteness, and cultural safety requirements is most acute — are particularly underserved. The rural and remote health access gap documented across the Australian health system is especially pronounced in aged care, where regulatory standards designed for metropolitan providers are applied uniformly to vastly different operating contexts.
5. Younger People in Residential Aged Care
Approximately 2,800 people under the age of 65 remain in residential aged care — a figure that persists despite the explicit policy objective, dating to 2006, of reducing it to zero. These are typically individuals with acquired brain injuries, neurological conditions, or complex disability profiles whose support needs have defaulted into the aged care system rather than being absorbed by the NDIS. The interface between the NDIS and aged care remains complex, under-resourced, and disputed at the individual level. A time-bound sunset clause — under which all eligible under-65 residents must transition to NDIS-funded community or specialist accommodation within a defined period — has not been legislated.
6. Financial Transparency
Government funding is provided to residential aged care providers as approved provider grants and per-resident subsidies. How providers allocate those funds between direct care, administration, and profit is not subject to mandatory public disclosure in a standardised, auditable format. The Aged Care Financing Authority has produced annual reports on sector finances, and new reporting obligations have been introduced, but full transparency — specifically, the percentage of government funding allocated to direct care versus overhead and profit — remains voluntary in practice. This prevents meaningful accountability for public investment.
Support at Home (2025 Reform): Promise and Risk
The Support at Home program, commencing 1 July 2025, is the most significant structural change to home care in decades. It replaces the fragmented CHSP and HCP programs with a single, unified framework. Under the new model, eligible individuals receive an individual budget allocation across four funding categories, giving consumers greater direction over the services they access.
The reform is philosophically aligned with the Royal Commission's consumer-direction principles, and its potential to reduce the wait list backlog — by eliminating the tiered package structure that produced queuing distortions — is real.
The risks are also significant. Providers require substantial system investment to manage the new model's administrative requirements. Budget adequacy will determine whether the reform delivers on its unmet demand reduction objectives or simply redistributes the same shortfall more equitably. Transition disruption — particularly for vulnerable recipients currently receiving CHSP services who may face reassessment delays — requires active monitoring through the 2025–26 period.
Policy Recommendations for Completion
The Royal Commission laid out a comprehensive reform agenda. The following represent the most urgent outstanding actions required to complete it:
1. Mandate allied health minutes alongside nursing minimums in residential aged care — specifically physiotherapy, occupational therapy, and dietetics — based on resident acuity profiles.
2. Full transparent reporting of government funding allocation to direct care versus administration and profit, by provider, as a condition of approved provider status — not a voluntary disclosure regime.
3. Rural and remote provider sustainability funding that operates independently of fee-for-service revenue — recognising fixed costs in thin markets and ensuring minimum clinical standards are achievable outside metropolitan areas.
4. National Dementia Strategy with legislated minimum training standards for the aged care workforce, and expanded reach of the Dementia Support Program to meet the documented prevalence of the condition in residential settings.
5. Legislated sunset clause on under-65 residential aged care, with a defined transition timeline and NDIS interface obligations, eliminating the remaining policy ambiguity that has sustained this cohort in inappropriate settings for two decades.
6. Parliamentary aged care oversight committee with biennial public reporting on Royal Commission implementation progress — providing an accountability mechanism that outlasts any single budget or electoral cycle.
Conclusion
The Royal Commission into Aged Care Quality and Safety produced the most comprehensive critique of a major Australian government system in a generation. The legislative and funding response since 2021 has been genuine and, in some areas, substantial. The AN-ACC funding reform, the Star Ratings system, the 24/7 RN mandate, and the new Aged Care Act 2024 are not trivial achievements.
But reform of a system characterised as a "national disgrace" requires more than legislative passage. It requires consistent enforcement, adequate resourcing relative to population need, and the political will to close the gaps that remain — in staffing, in dementia care, in rural access, in financial transparency, and in the protection of the most vulnerable cohorts the system serves.
For related analysis, see our assessments of rural and remote health access, mental health and Medicare reform, and the Indigenous health gap.
Coalition for Better Health advocates for evidence-based health policy reform in Australia. This analysis is produced independently and does not represent the position of any government agency or political party.