Last week's Brisbane hearings of the Aged Care royal commission highlighted fundamental problems with the regulation of our aged care system.
As well as nursing home residents, their families and staff, it was a respected academic - engaged by the federal government previously - whose evidence was most damning.
Professor Ron Paterson said Australia's "broken" aged care regulatory system was putting older people at grave risk.
In his explosive evidence, he said regulators pay lip service to older people's welfare but are so desensitised to poor care that they allow bad nursing homes to stay open.
He said there's too much consultation and not enough action and raised concerns about the influence of aged care providers.
In 2017, the government commissioned he and Kate Carnell to examine South Australia's Oakden nursing home scandal.
The review made 10 recommendations around consumer protection as the most important element of aged care.
Recommendations included consumers being able to engage in relevant aspects of the regulatory framework, protection of rights, compulsory reporting of serious incidents, improved monitoring of aged care facilities and moving towards unannounced visits based on risk profiling of nursing homes.
While giving evidence, Professor Paterson appeared frustrated that those recommendations may have been accepted in principle but little has been done to implement them.
The one reform that has gone ahead is the merging of complaints and regulation into one organisation.
The Aged Care Quality and Safety Commission began operating from January 1.
I have previously condemned this new body.
The royal commission hearings prove that it's not the tough cop that the government promised it would be.
We see it here in the Hunter and across the country.
Nursing homes that consistently fail basic standards of safety and quality continue to operate with little or no sanctions.
The regulators knew of major issues at the Earle Haven nursing home on the Gold Coast - from where residents were recently evacuated - but let it remain open.
My issue with the new body is that it is just a merger of agencies that have been regarded as ineffective because they lacked independence, transparency and accountability.
The royal commission heard that more than 25 percent of people are dissatisfied with the new body's handling of their complaint.
Professor Paterson was asked about the issue of transparency.
He and Ms Carnell had recommended that Australia adopt a similar system to that which operates in the UK and US where complaints and investigations are made available to the public.
The availability of such material allows families to make an educated and informed decision about where to put their loved ones.
"These are publicly-funded providers and they are providers who are caring for the most vulnerable members of our community.
Why would the default position be secrecy of information about the providers?" was Professor Paterson's sensible reply.
Senior Counsel Assisting the Royal Commission, Peter Gray, summed up the situation.
"The evidence this week has exposed serious defects in the regulation of quality and safety of aged care at both the operational level and the design level. Equally concerning, these defects are old news. Government has been tardy in implementing previously recommended forms," he said.
Rather than regulator name changes, we need proactive and structural regulatory reform together with measures that prevent inadequate clinical care and neglect of aged care residents.
The key reform agenda is the quality of the aged care workforce.
One fundamental problem yet to be considered by the royal commission is the Aged Care Act (1997).
This Act, brought in by the Howard government, helped make aged care very attractive to investors.
Over the course of the past 20 years, we've witnessed quality of care compromised by commercial interests.
The Act requires a complete overhaul.
We need quality data on the incidence of pressure sores, falls, infection/sepsis rates and medication errors.
If such data exists it is not publicly available.
Without it, we're left with the horror stories, unchallenged.
There are many good residential aged care facilities.
The problem is being able to locate them.
No government in the past 20 years has been prepared to tackle Australia's aged-care crisis.
The government must act on the commission's findings so this expensive exercise doesn't go the same way the many inquiries before it have gone.