Intended for healthcare professionals


Health and welfare of older people in care homes

BMJ 2007; 334 doi: (Published 03 May 2007) Cite this as: BMJ 2007;334:913
  1. Marion E T McMurdo, professor,
  2. Miles D Witham, clinical lecturer
  1. Ageing and Health Division of Medicine and Therapeutics, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY
  1. m.e.t.mcmurdo{at}

    Improvements will depend more on reform of the whole system rather than on commissioners and champions

    The welfare of older people who live in care homes has raised concern for decades in many countries.1 Scandals surface on a depressingly regular basis, and although these enter the public consciousness, none provokes the outcry caused by reports of abuse of vulnerable people at the opposite end of the age range—children.

    Two recent campaigns by the charity Age Concern England and partners focused on lack of respect for the dignity of older people. “Hungry to be heard” examined the problem of malnutrition in older people in hospital,2 and it called for more help for those needing assistance with eating and drinking. But protecting patients' meal times from interruption will prove a difficult goal for frazzled staff in many acute hospital units. “Behind closed doors” campaigned for people to be able to use the toilet in private in all care settings and argued that this was a general marker of whether human rights and dignity were being respected.3

    Both reports bring fresh impetus to important topics but deal with issues that have been around for a discouragingly long time. The landmark study on malnutrition in hospital was published in the BMJ as long ago as 1994, yet problems persist and solutions remain elusive.4 Of course, both illness and dependency pose threats to dignity, but people of all ages have a fundamental right to be respected. So why is dignified respectful care for older people still lacking, and what might restore it?5

    Legislation, regulation, and standard setting are widespread in the health and care home sectors, and more of the same seems unlikely to alter attitudes and prejudices. There is a current vogue to appoint champions and commissioners for older people. Such appointments may allow a degree of self congratulation that something is being done for older people, but risk simply being a way of avoiding the difficult business of system change. Older people are the core business of the care sector; thus, what is needed is not just individual advocates but rather a long overdue and major change in culture and practice to reflect the central position of older people in systems of care.

    How might this be achieved in care homes? Firstly, we need to stop blaming individual practitioners and care homes. Good people working in poor environments with poor systems of care will inevitably produce poor quality care, as has been shown in health care.6 A whole systems approach is much more likely to succeed; for example, changing infrastructure, procedures, management techniques, and staff training.7 Such an approach is beginning to reap dividends in terms of patient safety in health care.8 Frontline care staff should not be made scapegoats; instead, their dignity should also be assured.9 Being valued (in financial and non-financial terms) and able to work in a system, atmosphere, and culture that recognises and rewards good quality, informed, thoughtful care is much more likely to be effective than merely providing more training.10

    Secondly, access to good quality medical care should be readily available. Older people in care often have complex medical problems, yet their care is mostly provided by general practitioners, rather than specialists in the medicine of old age.11 Most older people in care are unable to initiate a referral for a medical review. They depend utterly on care staff to recognise that any abrupt change in their condition—for example, a sudden loss of mobility—is likely to be a marker of underlying illness, which should be assessed, diagnosed, and managed. While some general practitioners relish the challenges of their role in care homes, others lack the skills, support, or inclination to fulfil this unsought but demanding role. Primary care teams need to be supported by secondary care specialists and should be given time, money, incentives, and training in comprehensive geriatric assessment. Such an approach would improve the quality of care for people in institutional care. It would also enable more elderly people to live successfully in the community without the need for institutional care.12

    Older people have an important part to play too. The political impact of older people as a lobbying force is weak in many, but not all, countries. When older people become politically organised they are a large and formidable force that has real power to campaign for change, as has been shown by the American Association of Retired Persons. Older people need to demand that carers are paid a decent wage and are well trained, that managers are responsive to their needs, that buildings are fit for purpose, and that vulnerable older people are not denied the expert health care that they are entitled to. All of this costs money, and those of us in affluent countries need to pay more to ensure that care for older people is of a standard that we ourselves would be happy to receive.


    • Conflict of interest: None declared.

    • Provenance and peer review: Commissioned, not peer reviewed.