22. Over more than five years, the Inquiry heard about survivors’ moemoeā (dreams) for the future. Survivors, their whānau and support networks told the Inquiry that they want to see an Aotearoa New Zealand where every child, young person and adult is loved, safe and cared for in a manner that supports their growth and development into a thriving contributor to society. Survivors’ moemoeā are summarised below.

He moemoeā ā ngā purapura ora mo te heke mai
Survivors’ dreams for the future

• Aotearoa New Zealand’s care system is broken. Survivors want to see a total overhaul and fundamental change to ensure that this national catastrophe does not continue.
• Survivors told the Inquiry that the care systems need to fundamentally change. This would see the State handing over power, funding and control of preventative supports and care services to local communities and communities of interest.
• Survivors want every whānau supported so they can provide loving care themselves. That means they must receive the supports they need, when they need these and for as long as needed, to realise their full potential and flourish. Additional daily care support may be required to avoid out-of-whānau care. Faith-based institutions would exit the business of care and in their pastoral care adopt national standards and transparent complaint processes.
• From time to time, out-of-whānau care will be required. When out-of-whānau care is required, it must be short-term. It must be delivered by the community, hapū or collective and the individual and their whānau have control of decisions on care. Out-of-whānau care should only be used to give the wider whānau time to receive holistic support, for example for healing or resetting, so they can be brought back together. Everyone in the community works to return that child home. Out-of-whānau care will be in plain sight, with children safeguarded in multiple ways and wider whānau/family connections maintained at all times.
• Local schools are welcoming and inclusive of all students and all students have their diverse needs met and achieve to their potential.  Children, young people and adults receive the disability or mental health supports they need.
• The Crown must cede authority and live up to the promise of te Tiriti o Waitangi. Whānau, hapū and iwi must be able to exercise their right to tino rangatiratanga over kāinga and are empowered to care for their tamariki, rangatahi, pakeke and wider whānau according to their tikanga and mātauranga. The mana of all individuals, communities and whānau must be restored. 
• Human rights are respected, made real, and embedded into law to support people to avoid out-of-whānau care and give greater protection to people who may require care of their choice in the community.
• In faith-based institutions, leaders providing pastoral care reflect the diversity of their communities and expression of that diversity is welcomed. Respect for te Tiriti o Waitangi, human rights for all people and freedom of belief simultaneously flourish.  Faith community members are free to choose partners, seek appropriate health care and have no fear of being shunned.
• Communities, hapū and iwi must be enabled and empowered to design, implement, innovate and control how the care systems operate for their community. The Government should invest in communities that have levels of social deprivation, support communities to identify those in need, understand the evidence of what works to prevent the need for a care intervention, take an early investment approach and measure long-term outcomes in communities.
• Survivors spoke in detail about local communities defining the preventative work, support services and out-of-whānau care. Survivors and whānau took the Inquiry to examples in the community where this is happening – where hapū provide a full preventative service to whānau.
• Survivors acknowledge that devolving power, funding and control from the State into local hands will take time. It will require several stepping stones to get there. Some local communities or communities of interest will be ready now, so these steps can be taken immediately.  Others will need extra support and investment before they can take on new or expanded roles in providing services and supports.
• Most significantly, survivors want the State to radically change its attitude and practices relating to care decision-making and investment, which are characterised by low trust and a focus on risk aversion and crisis response rather than empowering whānau and local communities to look after their own.

23. Survivors’ moemoeā set the foundation for the Inquiry’s own vision for the future – he Māra Tipu (a growing garden). The concept of he Māra Tipu was introduced in the Inquiry’s 2021 interim report He Purapura Ora, he Māra Tipu: From Redress to Puretumu Torowhānui. The name of the report drew on the whakataukī “he purapura ora, he māra tipu”, which reflects the idea that a seedling, despite being trampled upon and losing part of itself, still has infinite potential to grow and regenerate.[13]

24. The Inquiry also considered the large body of evidence from survivors, their whānau and support networks; from hapū, iwi, Māori, and Pacific Peoples; from disability communities; from advocacy groups, and experts; from former and current staff of care settings; and from religious leaders and religious communities. These witnesses described their experiences both during the Inquiry period and after 1999. The evidence the Inquiry has heard, including about survivors’ issues and experiences after 1999, has clearly demonstrated that the current care system is not fit for purpose.

25. Due to the constraints of the Terms of Reference, the Inquiry cannot set out the full pathway to reach he Māra Tipu. It can, however, recommend the first steps that survivors, local communities, the State and faith-based entities should take on the journey towards he Māra Tipu. The recommendations in Chapters 4–8 do just that. The full description of the Inquiry’s vision for the future – he Māra Tipu – is set out in below.

Ngā haukerekere a ngā mahi tūkino
Abuse and neglect in care was widespread and systemic

26. The care system in Aotearoa New Zealand was a fully funded failure that enabled pervasive abuse and neglect. The State and faith-based institutions took on responsibility for caring for over half a million babies, children, young people and adults between 1950 and 1999, but did not keep them all safe.

27. In the Inquiry period, families, whānau, kāinga and communities needed support to care for their children, young people and adults in care in their homes and communities. Many faced significant challenges, including poverty, impacts of colonisation, and family violence, or had unmet needs due to disability or experience of mental distress. The State removed children, young people and adults from their whānau and support networks and placed them into care settings, many of which were harmful and abusive. Societal attitudes reflecting racism, ableism and sexism and punitive attitudes towards children and young people made some people more likely to be placed in care and more likely to experience abuse there.

28. Children, young people and adults were abused and neglected in the care of the State and in the care of faith-based institutions. They were in social welfare residences and institutions, foster care, disability and psychiatric care, schools, orphanages, faith communities, unmarried mothers’ homes, health camps, and the care of NZ Police. This Inquiry was the first opportunity we have had in Aotearoa New Zealand to examine the care system as a whole. No inquiry locally or overseas has had such a wide mandate. The Inquiry found pervasive abuse and neglect everywhere it looked.

29. Survivors described many kinds of physical, sexual, psychological and emotional abuse and neglect while they were in care. Some groups experienced targeted abuse and neglect that was specific to who they were – including Māori, Pacific Peoples, Deaf, disabled people, people who experience mental distress, Takatāpui, Rainbow, and MVPFAFF+, and women and girls.  Some survivors were subjected to solitary confinement and forced labour.

30. The harm and trauma suffered by children, young people and adults in State and faith-based care has affected every part of their lives. Almost every survivor who came forward to share their experience with the Inquiry has endured irreparable damage to the quality of their lives.

31. For too long society in Aotearoa New Zealand has been unwilling to accept that abuse and neglect in State and faith-based care was widespread and systemic. It did not occur solely due to the actions of a few ‘bad apples’ but was deeply rooted and enabled across all levels of the systems responsible for providing care. Nor was it a small failure that solely affected survivors. It was pervasive throughout the Inquiry period with devastating, multigenerational effects for survivors, their whānau and society as a whole.

32. The abuse and neglect experienced by survivors has contributed to an intergenerational transfer of inequities, including poorer physical health, mental health, education and employment outcomes, family and intimate partner violence, substance misuse and abuse, and fewer opportunities for many. One of the greatest costs is the loss of generations of adults who might otherwise have positively contributed to their whānau and community. Abuse and neglect in care contributed to, and in many ways created, the ‘care to custody’ pipeline and the formation and entrenchment of gangs in Aotearoa New Zealand, costing society both in terms of victimisation and the direct costs of policing and imprisonment.

33. The Inquiry has found that around 200,000 people were abused in care between 1950 and 1999. However, the true number of survivors could be much higher. The estimated total economic cost of this abuse and neglect is around $200 billion.[14] This amount is:

a. over three times what the New Zealand government spent on war and rehabilitation during World War Two (£615 million in 1946, which, adjusted for inflation, is $63.2 billion in 2023)[15]
b. over three times the cost of the government’s COVID-19 Response and Recovery Fund ($61.6 billion in 2022, or $67.9 billion in 2023 adjusted for inflation)[16]
c. almost four times the cost of the 2010–2011 Canterbury earthquakes response and recovery ($57 billion, adjusted for inflation for 2023), based on:

i. total estimated insurance claim costs, including private insurers and the Earthquake Commission ($38 billion in 2021, or $44.8 billion in 2023 adjusted for inflation)[17]
ii. core Crown Canterbury Earthquake Recovery costs, excluding the Earthquake Commission ($7.6 billion in 2014, or $9.8 billion in 2023, adjusted for inflation)[18]
iii. Christchurch City Council earthquake costs to date ($1.9 billion as at 2017, or $2.4 billion in 2023, adjusted for inflation)[19]

d. 100 times the cost of the 2023 Auckland Anniversary Day floods and Cyclone Gabrielle response and recovery ($2.021 billion).[20]

34. In fact, the estimated cost of abuse and neglect in care is more than the total of all of the above events combined.

He karonga te eke noa
An avoidable failure

35. Survivors, their whānau and communities, and our whole society have paid the price for this avoidable failure. Although a significant amount of resourcing has gone into providing care, for many people in care the money spent has not translated to better outcomes. At the same time, faith-based institutions continue to receive the financial benefits of tax-exempt status, despite the significant abuse and neglect that was perpetrated in their care.

36. Decision-makers have been told multiple times over the last 40 years about the deficiencies with our country’s care systems but their responses have not matched the magnitude of the issues. The Puao-te-Ata-Tū Report pointed this out in 1988:

“We need the co-ordinated approach that has been used to deal with civil emergencies because we are under no illusions that New Zealand is facing a major social crisis. The solutions to social problems lie in a co-ordinated attack on the problems, involving the resources of the private sector as well as the public and particularly of the people themselves.”[21]

37. The State continues to make incremental and disconnected attempts to improve care systems despite the increasing calls for urgent radical change. Continuing to tweak the status quo will not answer those calls. For the last 70 years, the State has taken responsibility for children, young people and adults who need care, but decisions about that care have largely been made by people with little connection to those going into care and their communities. This State-led model of care cannot be described as anything less than a dismal failure. Peter Whitcombe, Chief Social Worker, told the Inquiry that Oranga Tamariki staff sometimes refer to their residential care facility model as a “fully funded failure model”.[22]

38. Aotearoa New Zealand’s systems of care – in social welfare, disability, mental health, education and transitional settings – need a total overhaul and fundamental change. The ultimate outcome the Inquiry wants to see is a country where no child, young person or adult experiences abuse or neglect, and where every whānau who needs support is safe, is loved, and receives the supports it needs, when it needs them and for as long as it needs them, so that whānau members can realise their full potential and rights and live a good life as they define it. All the Inquiry’s recommendations must be fully implemented to improve the lives of survivors and of all New Zealanders.

Ko te mahi tūkino i ngā pūnaha taurima, e pā ana ki a tātou katoa
Abuse and neglect in care affects everyone

39. Aotearoa New Zealand has a reputation for being a safe place to grow up, raise a family, and grow old, but there is a dark side to our society that must be confronted and addressed – the abuse and neglect that around 200,000 people experienced while in State and faith-based care during the Inquiry period.

40. Many of the factors that contributed to abuse and neglect during the Inquiry period are not confined to the past. They are present today and continue to put people at risk of harm. Settings outside the Inquiry’s scope, such as rest homes or aged care facilities, sports clubs, community organisations and youth groups, have been the subject of international investigations and inquiries into abuse and neglect. It is highly likely that people in these settings in Aotearoa New Zealand have experienced abuse and/or neglect.

41. In Part 4, the Inquiry found that the 1970s had the highest rates and incidents of abuse and neglect, followed by the 1960s and then the 1980s.[23] The two generations born between 1946 and 1976 are therefore likely to know someone who was abused or neglected in care or to have experienced it themselves. The oldest of these generations are now increasingly requiring care and supports as they age. By 2028, over 1 million New Zealanders will be aged over 65.[24]

42. Internationally, Aotearoa New Zealand is often seen as a beacon of human rights and liberal progress. New Zealanders are proud of our country’s worldwide reputation for fairness, justice, and the protection of individual freedoms. However, this image contrasts starkly with our domestic reality, where we have a terrible track record of abuse and neglect in care settings. The Inquiry urges New Zealanders to consider its findings and recommendations and apply them more broadly than the scope of its investigation allowed.

He papa whāinga e hua ai ko te Māra Tipu
A fundamental shift is needed to reach he Māra Tipu

43. The Inquiry’s vision for the future includes one of the most fundamental changes to systems of care this country has ever seen. It would see the State handing over power, funding and control of supports and services to individuals, groups and organisations chosen by collectives and/or local communities. Current systems of care will never truly serve or meet people’s needs until people and communities are enabled and empowered to design, innovate, implement and control how the care systems operate. The Inquiry sees collectives and local communities defining themselves and grouping together to design and deliver supports and services according to shared values, goals, experiences, needs, location, interests, ancestry, whakapapa, ethnicity, religion and/or culture. This is consistent with international practice, which has seen a shift towards the use of community-based services where possible, and consideration being given to how to best address the needs of and improve outcomes for whānau and communities more broadly.

44. Devolving power, funding and control from the State will take time. It will require several stepping stones along the pathway to get there. The Inquiry envisages that the first steps will include the care settings within the Inquiry’s scope – social welfare, disability, mental health, education and transitional settings – but that, over time, other social services could be devolved to communities. At the same time, the Inquiry pictures significant downsizing and/or disestablishment of government agencies currently designing and delivering care. The Inquiry does not foresee Oranga Tamariki as part of he Māra Tipu. The Inquiry would expect to see other agencies involved in the care system, such as the Ministry of Health, Whaikaha and the Ministry of Education, reducing in size and shifting focus to supporting collectives and local communities.

45. Some collectives and/or local communities will be ready for the State to devolve power, funding and control now, so the first steps towards he Māra Tipu can be taken immediately. Others will need extra support and investment before they can take on new or expanded roles in providing services and supports. Most significantly, the State will need to radically change its attitude and practices relating to care decision-making and investment, which are characterised by low trust and a focus on value for money rather than empowering collectives and/or local communities to look after their own.

46. The Inquiry’s vision is for Māori to exercise tino rangatiratanga over kāinga and to care for their mokopuna, uri and whānau in line with te Tiriti o Waitangi. Alongside the transformation in the provision of care, there is a need for a mature and fair conversation and process about New Zealand’s constitutional arrangements and how to give effect to the vision in te Tiriti o Waitangi of a true partnership between two peoples.

47. The Inquiry’s vision for the future includes human rights being fully realised for all. This would include the rights guaranteed to women, children, Māori (as an indigenous people under the United Nations Declaration on the rights of Indigenous Peoples), Deaf, disabled people and people who experience mental distress.

48. As the Inquiry noted in Part 1, in Aotearoa New Zealand our te Tiriti o Waitangi and human rights protections, including those contained in the United Nations Declaration on the Rights of Indigenous Peoples, are set out in a variety of statutes and the common (court-made) law.[25] This means they are not all in one place and not all rights have been incorporated into our domestic law. In the future, the Inquiry envisages the rights guaranteed by te Tiriti o Waitangi and economic, social and cultural rights being enshrined in legislation alongside civil and political rights. These new statutory rights should be subject to a supermajority of 75 per cent of all members of Parliament being necessary to change or repeal it. This will protect the legislation from the influence of our comparatively short Parliamentary terms and help maintain their long-term integrity. These changes will also form part of the constitutional conversation that Aotearoa New Zealand needs to have.

49. Again, these ideas are not new. For example, more than 35 years ago the Pūao-te-Ata-Tū report called for government to “harness the initiatives of the Māori people and the community at large to help address the [social] problems” and “…promote and sustain community responses”.[26] Other jurisdictions, including the United States and Australia, made significant shifts towards devolving child protection decision-making to indigenous communities in the 1970s and 1980s.[27] Australia also made a transformational shift in the provision of disability services and supports in 2013 using a person-centred insurance model under the National Disability Insurance Scheme, enabling disabled people to choose and control who provides their support. In 2019, Canada passed legislation affirming the right of indigenous peoples to self-determination, including jurisdiction in relation to child and family services.[28]

50. The Inquiry sees a future where there is minimal, if any, need for any child, young person or adult who needs support to be placed in out-of-whānau care. Individuals and whānau will have everything they need to flourish and their mana will be enhanced. In he Māra Tipu, survivors will have the supports and tools they need to heal and thrive and live a fulfilling and productive life. In he Māra Tipu, Māori and the Crown will be genuinely partnering to realise the promise of te Tiriti o Waitangi. Whānau, hapū and iwi will exercise tino rangatiratanga over their kāinga and be empowered to care for their tamariki, rangatahi, pakeke Māori and whānau according to their tikanga and mātauranga.

51. The Inquiry cannot map the full extent of the pathway to achieve its vision of he Māra Tipu. The Inquiry can provide navigation lights based on its findings and observations. Once its recommendations have been implemented, survivors, people receiving supports and services, whānau, collectives and local communities, the State and faith-based entities should review how far they have come, how much progress has been made, and together, map out the steps they need to take to achieve the vision.

He Māra Tipu – He pūnaha taurima mo te heke mai
He Māra Tipu – what will the future care system look like?

52.  In this Part, the Inquiry uses “faith-based entities” to refer to organisations with a faith-based interest involved in providing care supports and services. The Inquiry does this to distinguish between the “faith-based institutions” as defined in its Inquiry’s Terms of Reference, which were the subject of its investigations into abuse and neglect of people in their care between 1950 and 1999. The Inquiry envisages that a broader range of denominations and religious groups may be involved in providing care in the future.

Ngā mahi ā ngā momo hinonga o te pūnaha taurima
Functions of different entities in future care system

Individuals and whānau

• Access supports and services from care providers and other providers.

Care providers
(including individuals, rōpū, NGOs, faith-based entities, organisations, hapū, iwi)

• Provide supports and services tailored to meet community needs (including care and protection, youth justice, disability, community mental health) ($ via Commissioning Agency)
• Comply with National Care Safety Strategy and statutory rules, standards and guidelines
• Investigate and report on complaints
• Care providers are accredited
• Staff and care workers are registered
• Prospective staff are screened and vetted
• Staff and care workers are trained
• Collect and keep full and accurate records

Independent entities

Puretumu Torowhānui Agency

• Implements puretumu torowhānui system and scheme

Care Safe Agency

• Whole of system leadership on preventing and responding to abuse in care
• Develops National Care Safety Strategy and action plan
• Sets, monitors and enforces statutory care safety rules and standards
• Investigates and reports on complaints
• Keeps national register of substantiated complaints
• Accredits care providers and other providers
• Registers staff and care workers
• Leads public awareness, education and prevention initiatives
• Develops training and education for staff and care workers
• Undertakes research, data analysis and horizon scanning
• Provides advice to Government on prevention and responding to abuse

Core Public Service

Care System Office (later to become the Ministry for Care System)
Departmental agency with Chief Executive & Advisory Board

• Implements Inquiry recommendations and reports on progress
• Coordinates all government care services funding to Commissioning Agency (funding amounts decided by Ministers/Cabinet)
• Facilitates public participation/ collaboration on implementing recommendations
• Facilitates and coordinates with other departments involved in providing care services and supports
• Monitors performance of Care Safety Agency, Commissioning Agency and Puretumu Torowhānui Agency
• Provides policy advice to Ministers on care system as a whole
• Administers Care Safety Act (and makes law changes)

Ministry of Health

• Provides policy and funding advice on mental health matters to Ministers
• Administers relevant legislation (eg, Mental Health (Compulsory Assessment and Treatment) Act, Pae Ora Act)

Collectives and/or local communities
(including individuals, rōpū, NGOs, faith-based entities, organisations, hapū, iwi)

• Allocated $ from Commissioning Agency
• Procure supports and services (including care and protection and youth justice, disability, community mental health) from care providers
• Invest in communities’ and care providers’ capacity and capability building

Other providers (schools and hospitals)

• Contracted by Commissioning Agencies
• Provide inpatient mental health and education supports and services (contracted via Commissioning Agency)
• Comply with National Care Safety Strategy and statutory rules, standards and guidelines • Investigate and report on complaints
• Providers are accredited
• Staff and care workers are registered
• Prospective staff are screened and vetted
• Staff and care workers are trained
• Collect and keep full and accurate records

Commissioning Agency
Independent Crown Entity with Board

• Allocates funding to collectives and/or local communities for supports and services (including care and protection and youth justice, disability, community mental health) and for capacity and capability building
• Contracts delivery of inpatient mental health and education supports and services from hospitals and schools

Independent oversight bodies

• Investigate and report on complaints brought by users of supports and services
• Proactively inspect care providers and other providers

Whaikaha

• Provides policy and funding advice on disability matters to Ministers
• Administers relevant legislation (eg, NZSL Act)

Ministry of Social Development

• Provides policy and funding advice on care and protection and youth justice matters to Ministers
• Administers relevant legislation (eg, OT Act)

Ministry of Education

• Provides policy and funding advice on education matters to Ministers
• Administers relevant legislation (eg, Education and Training Act)

53. The diagram above describes the functions of the different entities in the care system:

a. Individuals and whānau who need support can:

i. access the supports and services they need from care providers and/or other providers (such as hospitals and schools) in their local communities
ii. raise concerns (about the individual’s wellbeing or care providers’ practice) or make complaints directly to care providers or other providers, to the Care Safe Agency, and/or to Independent Oversight Bodies.

b. Collectives and/or local communities: will be allocated funding by the Commissioning Agency to procure supports and services tailored to meet community needs from care providers, and to invest in community and care provider capacity and capability building. Collectives could include individuals, rōpū, NGOs, faith-based entities, organisations, hapū, iwi, etc.
c. Care providers: collectives and/or local communities will procure supports and services from care providers. Care providers could include individuals, rōpū, NGOs, faith-based entities, organisations, hapū, iwi, etc. They will be responsible for:

i. providing preventative and holistic supports and services tailored to meet community needs (including care and protection, youth justice, disability and community mental health services)
ii. complying with the National Care Safety Strategy and the rules, standards and guidelines set by the Care Safe Agency, including implementing safeguarding policies and procedure, being accredited entities, having staff who are registered, screened, vetted and trained, collecting full and accurate records, investigating and reporting on complaints received by users of supports and services, and undertaking mandatory reporting.

d. Other providers: schools and hospitals will be responsible for:

i. providing inpatient mental health and education supports and services
ii. complying with the National Care Safety Strategy and the rules, standards and guidelines set by the Care Safe Agency, including implementing safeguarding policies and procedure, being accredited entities, having staff who are registered, screened, vetted and trained, collecting full and accurate records, investigating and reporting on complaints received by users of supports and services, and undertaking mandatory reporting.

e. Independent Entities:

i. Puretumu Torowhānui Agency: an independent Crown entity with a board, responsible for implementing the puretumu torowhānui system and scheme
ii. Care Safe Agency: an independent Crown entity with a board, the primary regulatory agency for the new national care safety regulatory system, with responsibility for:

- whole of system leadership on preventing and responding to abuse in care
developing the National Care Safety Strategy and its supporting action plan to prevent and respond to abuse and neglect in care
- setting, monitoring and reporting on care safety rules and standards
- investigating breaches of rules and standards and enforcing a range of sanctions and penalties against care providers, staff and care workers
- investigating and reporting on complaints received directly from users of supports and services
- collating and keeping a national register of complaints and the outcomes of investigations from State and faith-based care providers, other providers of supports and services, professional registration bodies and Independent Oversight Bodies
- accrediting care providers and other providers of supports and services
- registering staff and care workers who are not already covered by existing professional registration regimes
- setting training and education standards and developing curriculums for staff and care workers
- workforce development and career pathways for staff and care workers
- leading public awareness, education and prevention initiatives
- undertaking research, data analysis and horizon-scanning
- advising government on prevention and responding to abuse and neglect in care, including where systemic deficiencies are identified.

iii. Commissioning Agency: an independent Crown entity with a board, responsible for:

- allocating funding to collectives and/or local communities so they can procure supports and services from care providers
- allocating funding to collectives and/or local communities to invest in capability and capacity building
- contracting delivery of inpatient mental health and education supports and services from hospitals and schools.

iv. Independent Oversight Bodies (the Ombudsman, Te Kāhui Tika Tangata Human Rights Commission, Health and Disability Commissioner, Mana Mokopuna): work collaboratively to proactively investigate care providers, hospitals and schools, and investigate and report on complaints brought by users of supports and services.

f. Departments of State:

i. Care System Office: a departmental agency with its own chief executive and advisory board, responsible for implementing the Inquiry’s recommendations. It will: facilitate effective participation of Māori in accordance with te Tiriti o Waitangi and public engagement and co-design to implement the Inquiry’s recommendations; report publicly on implementation progress, coordinate advice to Ministers on the total amount of funding for the Commissioning Agency; monitor the organisational performance of the Care Safe Agency, Commissioning Agency and Puretumu Torowhānui Redress Agency; provide policy advice to Ministers on the care system as a whole; and administer the Care Safety Act.
ii. Other government departments: would continue to provide policy and funding advice to Ministers responsible for the care system and administer relevant legislation (other than the Care Safety Act).

54. In he Māra Tipu, the State’s role in the care system will be focused on:

a. providing sufficient and sustainable investment in the care system, including investment in capacity and capability building, and design and delivery of care and support services, to realise he Māra Tipu
b. reporting to government, Parliament and the public on the use of public monies to invest in the care system
c. administration of legislation relevant to the care system, including legislation that upholds the rights of children, Deaf, disabled people, and people experiencing mental distress
d. collaborating with people in care, survivors, whānau and communities on new legislation or amendments to existing legislation relevant to the care system.

55. In he Māra Tipu, power, investment and decision-making about care services have been devolved from the State to collectives and local communities. The new arrangements for procuring preventative supports and services (through the Commissioning Agency and collectives and/or local communities) will drive strong, evidence-based investment approaches that will:

a. meet the aspirations and needs of people and whānau in need
b. achieve the best possible outcomes for people in need
c. achieve fair outcomes for all people in need
d. enable early investment to prevent, reduce and delay the need for out-of-whānau care.

Ngā hua Māra Tipu
He Māra Tipu outcomes

56. The Inquiry’s vision for the future – he Māra Tipu – will be realised when the following outcomes are in place:

a. survivors of abuse and/or neglect in care have the supports and tools they need to heal, thrive and live fulfilling and productive life
b. the mana and mauri of every child, young person or adult in care is recognised, upheld and enhanced
c. no child, young person or adult experiences abuse or neglect
d. all individuals and whānau have everything they need to flourish
e. any individuals or whānau who need support are safe, are loved, receive the supports they need, when they need them and for as long as they need them, to realise their full potential and live a good life as they define it
f. te Tiriti o Waitangi rights and human rights protections, including those in the United Nations Declaration on the Rights of Indigenous Peoples, and economic, cultural and social rights, are given effect through incorporation into domestic law that is subject to a supermajority to change or repeal it
g. whānau, hapū and iwi can exercise tino rangatiratanga over their kāinga and to care for their mokopuna, uri and whānau
h. the human rights of Deaf, disabled people, and people who experience mental distress, are fully realised through standalone legislation that protects and strengthens these rights, including through giving effect to the United Nations Convention on the Rights of Persons with Disabilities
i. few, if any, children, young people or adults need out-of-whānau care
j. collectives and local communities have the investment, capability and capacity to proactively prevent and reduce harm in their communities, and are empowered to design, implement and deliver locally led supports and services for people who need them
k. entities and people providing supports and services are safe, highly trained, skilled and well paid, and representative of those in care.

Te parau Māra Tipu
The pathway to he Māra Tipu

57. The Inquiry foresees at least three phases of work on the pathway to realising he Māra Tipu between now and 2040:

a. Phase 1 (2024–2030): Implementing the Inquiry’s recommendations and consolidating change
b. Phase 2 (2031): Review Phase 1 and implement next steps towards he Māra Tipu
c. Phase 3 (2032–2040): Review Phase 2 and implement final next steps towards he Māra Tipu

58. There is a significant programme of work involved in implementing the Inquiry’s recommendations and realising he Māra Tipu. This will involve many stakeholders and parties working together to achieve this shared vision. Government, faith-based entities, hapū, iwi, communities and organisations each have a critical role.

59. Embarking on the pathway to he Māra Tipu includes a significant shift in how government and faith-based institutions work with communities. It is critical that all voices are heard and have opportunities to participate, make shared decisions and have ownership over the changes that will occur.

60. The process for implementing recommendations must give effect to te Tiriti o Waitangi and the United Nations Declaration on the Rights of Indigenous Peoples and enable Māori-led approaches. There must also be a process of co-design with affected communities, including children, young people and adults in care, survivors, Māori, Pacific peoples, culturally and linguistically diverse communities, Deaf, disabled people, people who experience mental distress, and Takatāpui, Rainbow and MVPFAFF+. This is discussed further in Recommendations 131–132.

61. The Inquiry envisages that community participation in the implementation of recommendations and the care system generally will shift over time. The Inquiry has identified three key phases, using the IAP2 Spectrum of Public Participation.[29]

Whāinga 1 (2024–2030): Te whakatinana i ngā whakatau o te Pakirehua me te whakatoka i ngā mea ka hua
Phase 1 (2024–2030): Implementing the Inquiry’s recommendations and consolidating change

62. The work during this phase would be initially led by the State and faith-based entities, increasingly involving people in care, survivors, whānau and communities in design and implementation.

63. The Inquiry envisages public participation in the design and implementation of these recommendations operating at the “collaborate/co-design” level on the IAP2 Spectrum of Public Participation. This means that the State and faith-based entities would partner with communities in every aspect of decision-making, including determining the issue/problem, developing solutions, assessing options and making choices.

Whāinga 2 (2031): Te arotake me te whakarite ahunga ki he Māra Tipu
Phase 2 (2031): Reviewing and deciding on next steps towards he Māra Tipu

64. The State, Māori, faith-based entities, people in care, whānau and communities jointly consider the outcome of the independent review into the implementation of the Inquiry’s recommendations (Recommendation 136) and identify the next steps needed to continue towards he Māra Tipu.

65. During this stage, there will be some activities that are occurring at the “collaborate/co-design” level on the IAP2 Spectrum of Public Participation, as discussed above. However, a key component of the review will be to identify the remaining steps to reach he Māra Tipu, where communities are empowered to make key decisions to minimise the need for out-of-whānau care (Recommendations 111–115) and in relation to provision of services for whānau in need of additional support. This would reflect the “empower” level of the IAP2 Spectrum of Public Participation.

66. For transparency and accountability, the State and faith-based entities would formally respond to the independent review by 31 December 2031, including on the next steps and the timelines for implementation of these (Recommendation 138).

Whāinga 3 (2032–2040): Te whakatinana i te ara whāinga ki he Māra Tipu
Phase 3 (2032–2040): Implement the next steps towards he Māra Tipu

67. The State, faith-based entities, people in care, whānau and communities partner to implement the next steps they have collaboratively identified following the independent review. By 2040, the care system reflects the vision – he Māra Tipu. In he Māra Tipu, power, investment and decision-making about care services have been devolved from the State to collectives and local communities.