GP services for older people: a guide for care home managers
Residents' entitlements and requirements - Being seen as an individual
All professionals should treat each resident as a person with experiences, aspirations and opinions, and not make assumptions about their capacity based on their age. People should be involved as fully as they wish in discussions about their health care and treatment. Provision of health services should be responsive to the needs of individual care home residents and reflect their wishes and preferences.
The home manager recently contacted a GP to discuss one resident who had suddenly stopped eating. Rather than considering whether this might be the effect of the resident's dementia, or the impact of new medication, the GP's response was to say, 'Oh well, she's 96, what do you expect?' The manager sees this as discrimination. 'If you went to your GP and she said, "Oh well, you're 54, what do you expect?", I don't think you would be happy with that or tolerate it. What difference does your age have to do with it?Care home manager 
Personalisation and personal budgets
Personalisation was initiated by people who use services and the disability rights movement. The core values of social work and social care that refer to dignity, respect and social justice reflect wider values of how we as individuals would like to be treated irrespective of age, disability and all the categories defined in the Equality Act 2007. While many professionals working with older people would agree with these values, in practice older people are still treated differently.
For disabled and older people receiving care and support at home, policies for personalisation have led to an emphasis on shaping support to the individual's strengths as well as their social and health care needs. The aim is to respond to their preferences and aspirations, take account of help from family, carers and community networks, and design a care package to fit.
Using direct payments and personal budgets, people have been able to create varied and flexible arrangements for securing care and support in ways that are tailored to their particular circumstances. The government has yet to provide residents with access to direct payments or personal budgets but increased choice, flexibility and involvement are now becoming more widely recognised in many homes as part of good practice. Choice and flexibility are reflected in two of the core standards defined by the CQC:
You should expect to be respected, involved in your care and support, and told what's happening at every stage – for example, you will be involved in discussions about your care, treatment and support. You will get support to help you make decisions and staff will respect your privacy and dignity. You should expect care, treatment and support that meet your needs – for instance, you can expect your care home to meet your needs relating to your cultural background, language, gender, disability, age, sexuality, religion or beliefs.
GPs and care homes should find ways to make the voice of the resident integral to care planning, as happens in the Thames Valley enhanced service scheme. There are benefits all round if relatives are also involved in care planning as much as they wish to and are able to. The Health Foundation suggests 'care partnership' groups, in which relatives are given a more structured role in care planning. The care partnership would include the resident, the care home manager, staff, an appropriate carer or relative, the GP and other health and social care professionals such as the community pharmacist. 
Ageism and other forms of discrimination
Ageism is deeply rooted in society as a whole, and influences attitudes and behaviour towards older people in a variety of ways. The Equality Act 2010 outlawed discrimination in the delivery of goods and services on the grounds of age, alongside other factors such as race, sex and disability, already covered in anti-discrimination law. It also put a general requirement on public bodies to promote equality. For care home residents, ageism in service provision can be guarded against if GPs and staff are proactive in identifying and treating long-term physical and mental health conditions.
The National Dementia Strategy confirmed that only a minority of people with dementia receive a formal diagnosis; but depression also often goes undiagnosed and untreated among older people in residential care, primary care and hospital settings. Depression, and the loss of confidence and competence that go with it, are not an inevitable feature of growing old. They are often a predictable response to the range of known factors commonly experienced by older people, including bereavement, disability and sensory impairment, incontinence, loss of independence, social isolation and lack of opportunities for meaningful activity.
Older people with mental health problems can be among the most socially excluded in society. The stigma of old age is amplified by the stigma of having a mental health problem, and may be further compounded by physical health problems and disabilities. Older people in residential and nursing homes are in many ways society's most excluded group. Up to 50% of older people in residential care have clinically severe depression, yet only between 10-15% receive any active treatment. 
Although less often referred to, care homes also reflect significant aspects of sexism and sex discrimination. More than 80 per cent of residents are women, and women make up the overwhelming majority of care staff and shift leaders. The persistent problems of inadequate funding and staffing levels, low pay, high vacancy and turnover rates, frequent use of agency staff and lack of access to training, are characteristic of sectors with a mainly female workforce. The consequences for residents include having to rely on unfamiliar staff for intimate personal care; limited staff knowledge and understanding of complex health and care conditions; loss of continuity of care and support; and less chance to form friendships with staff who know them well.
You may find the following resources useful:
Social CareTV: What is personalisation? (SCIE video, 2010)
Age equality and age discrimination in social care (SCIE, 2013)
Individualised care and co-production
Having lived alone since her husband's death over 20 years before, Alice moved into a care home aged 91 with a range of chronic physical and mental health problems. These included after-effects of a major heart attack 12 years earlier; proneness to falls; almost complete hearing loss; urinary incontinence; long-standing depression; some degree of dementia; confusion associated with urinary infections; suspicious feelings akin to paranoia; and periods of hearing and vocalising tormenting voices. For some time, because of Alice's deafness, her family had been communicating by writing information and questions on a pad for her to read and respond to, and the care home staff used the same method.
A few months after entering the home, Alice was refusing to take any of her medication, and was spending a good deal of time in a distressed, tearful state. Younger care staff were troubled that whatever they said or did, they could not find effective ways to comfort and console her. On the advice of the GP, the home manager involved a community psychiatric nurse (CPN) from the older people's mental health team, who in turn arranged for the consultant psycho-geriatrician to undertake an assessment visit, at which Alice's family were also present. He talked to the staff and relatives, and to involve Alice, despite her hearing loss, he too wrote his questions on a pad for her to read and answer.
On this basis, he was able to separate out the impacts of the different factors affecting Alice's mental health; prioritise the one principally associated with her experience of delusions, delirium and persecutory voices; and write a note explaining why it was particularly important for her to take the medication for that condition. He also discussed with her family and the staff, in terms of Alice's 'best interests' under the Mental Capacity Act, how far it was appropriate for staff to administer that particular medication concealed in food or drink.
All SCIE resources are free to download, however to access the following downloads you will need a free MySCIE account:
- Evidence review on partnership working between GPs, care home residents and care homes
- GP services for older people: a guide for care home managers
- Improving access to and experience of GP services for older people living in care homes: practice survey