‘Mr H is an ideal resident. He’s most grateful for anything that’s done for him.’ — Matron in Residential home.

Like a frozen frame in a film about musical chairs — no music, no movement — but everyone in a chair and every chair in its place lining the walls of the lounge. This image of an old people’s home is true only too often. The lounge is not a lounge at all. It’s a place to put people between meals. And old people’s homes are usually not homes at all —they are total institutions where residents are ‘managed’ and where the needs of the staff, rather than the residents, determine the order of the day.

Rewarded if they co-operate and punished if they try to assert themselves, an old person’s individuality is quickly crushed by a remorseless regime. For those in charge any real relationship with the old people threatens the home’s smooth-running schedule: talking interferes with ‘work’, ‘spoils’ the residents and raises their expectations.

And when the residents try to help themselves — by choosing their own clothes or making their own beds — they are often rebuked for being ‘too independent’ and labelled ‘unco-operative’. The Care Assistants are quicker and residents soon give up trying.

‘I had to come here, It had to be done. But it took the life out of me. It’s something that you lose. And it’s only them that loses it that feels it.’ — Resident in old people’s home.

The institution continues to undermine the old person’s independence by removing all sources of status, identity and worth. Many elderly women wear redundant aprons or rock dolls on their knees — a sad reminder of their lost roles as householder, mother, neighbour. Even control over personal finances is removed: pension books are taken away so that contributions for board and lodging can be deducted and ‘pocket money’ (sic) is doled out piecemeal on request.

As a final insult, there is no escape. The privacy of a single bedroom is a rare privilege. And people are denied the right to hold themselves aloof from others because the staff call residents by their first names.

The whole experience is reminiscent of the effect of solitary confinement on a prisoner.

‘Life ceases to have any significance for one who has been debarred from every activity and deprived of every relationship which gave it meaning. Usually the prisoner becomes indifferent to his surroundings, apathetic and incontinent.’ — Psychiatrist Anthony Storr.

Society locks old people up — then throws away the key. The staff of the home where I worked had only meagre information about the people in their care — some residents’ files only contained a list of possessions. And when people enter residential accommodation the files of doctors and social workers outside the home are often ‘closed’ and stored — with macabre significance — together with those of clients who have died.

Residents all tend to be treated by the same person, their own doctor having surrendered them as patients. Yet their family doctor can be the only fragile link with a rapidly disappearing past, the only person who still remembers their dead partner, the only one in whom they can confide with ease.

‘In society’s eyes the aged person is no more than a corpse under suspended sentence.’ — Simone de Beauvoir.

The theoretical criterion for admission to an old folks’ home is that the old person is too fit for hospital but not fit enough to remain within the community.

Many come to old people’s homes straight from hospital. Others are admitted after the death of a spouse. Still others are put into care because relatives, neighbours, doctors or social workers believe they can no longer ‘cope’ in their own homes.

But social disquiet or embarrassment comprise a disconcertingly large part of judgements about ‘coping’, which is often interpreted exclusively in physical terms. Lack of bodily cleanliness, hygienic surroundings and a balanced diet are often seen as sufficient reason to remove someone from their home.

Mr D. for instance, lived a very squalid life. In spite of special home help services, meals brought to his door (‘meals on wheels’), and the attentions of a district nurse, his small flat smelt abominably. He slept and lived in an armchair, preferring a familiar bucket to the new commode that remained unused on the landing. His swollen feet were supported on a pile of old newspapers in front of a constantly-burning electric fire. A rolled-up cigarette always hung sleepily, dropping ash, from his unshaven mouth; and his clothes, never changing, clung dirtily around him.

But Mr D. had grandchildren, who lived with him and gave him a lot of support — collecting his pension, providing food, making tea. Nevertheless, he refused medical treatment and began to have hallucinations until one night he tripped over the flex of his electric fire and was persuaded to go into hospital for his and his grandchildren’s safety. Three months later he died — confused and alone.

It is tempting to blame the institutions themselves for the way some old people are treated. But the institutions simply reflect the attitude of a whole society. To be without possessions, property and employment or to be physically or mentally ill, is a disgrace. We look at old people and see our own futures. And we banish our fear of ageing and death by setting elderly people apart from us.

When they find it difficult to maintain themselves in their homes we decide they will be ‘better off’ in an institution. But what we are usually saying is that we — the rest of the community — will be better off if the old are removed from us.

Being uprooted from familiar surroundings and admitted to hospital or into residential care can have a devastating effect on someone’s ability to manage. And being deprived of one’s life partner has been described as the biggest single tragedy of old age. Bereaved partners often become depressed and neglect both themselves and their homes. Intensive rehabilitation can help dramatically and allow old people to remain in the community where they belong. It has been estimated that nearly half the people in Britain’s homes for the elderly need not be there.

It costs around $200 a week to keep someone in a residential institution. But a flat with a warden, five hours’ home help and ‘meals on wheels’ five days a week would cost only half this amount. Ironically it is only now, when public expenditure is being severely curtailed, that concerted efforts are being made to care for the elderly in the community.

Britain is one country in the forefront of such developments. Specially designed flats with paid wardens are now found throughout the country. And a new development — very sheltered accommodation — is becoming increasingly widespread. In these flats people retain the independence of self-contained living but receive the same services as those provided in residential homes — domestic help, health care, help with food preparation.

Developments like these are a great improvement on life in an institution — but still tend to lump old people together away from the mainstream of life. More promising is the increasing support available to people in their own homes.

One principal of an institution in London calculated that her staff could provide a more effective service tending old people in their own homes. ‘I feel I could function with the same number of staff and the same number of elderly people — but without a building. I could organise my Care Assistants and domestic workers to work a five day week over seven days so that each elderly person would have companionship and help for not less than a concentrated four hours a day.’

Residents in her home were often alone for up to 12 hours a day. Her plan would provide the intensive one-to-one contact so lacking in an institution. And the old people could chose when to get up and go to bed, what and when to eat and live as they wanted to live.

Despite all these developments residential care may still be necessary for some people. But this should be seen as an integral and valued part of community services. With trained teams of people providing intensive rehabilitative supports, residential care could be used as a temporary measure — to give elderly people a rest and time to recharge while community supports are explored and prepared for their return. Old people want to be cared about, not cared for.

A day in the life... 4.45am Care Assistants stalk purposefully down corridors to begin dressing the first of the 19 residents who cannot dress themselves. No knocking on doors. Lights flicked on. Bedclothes pulled back. Begin at the bottom. Stockings pulled on, snappily followed by garters and shoes. Lavishly soaped flannel flapped around private — but oh, so public — parts. No rinse. Brisk rub with towel. Same flannel scoured over face. No rinse. Brisk dry. Hoist onto commode. Nightdress off. Knickers pulled up at half mast, other garments over head. Quick flick over soiled rubber sheet. Dirty linen to sluice room. Clean resident transferred from commode to bed again. 6.00 am Tea in plastic map dispensed from trolley travelling at break-neck speed along corridors. Residents loaded into wheel-chairs and decanted into dining room. Commodes, pots, bed-bottles, tea mugs sluiced out. Staff tea break. General moans about too much being expected from too few night staff — next shift, who had it ‘cushy’, would have to finish what they didn’t have time to do. 7.30 am Exit night staff and enter first shift of the day staff. Tea break. Remaining residents cajoled, wheeled, chivvied into dining room. Breakfast. 9.00 am Residents wheeled to ‘their’ chairs in ‘their’ particular lounge. Beds made. Tea break. Grumbles about night staff being lazy and not doing their jobs properly. Baths. The less heavy, more ‘co-operative’ residents are selected for bathing and their cleanliness triumphantly recorded in record book. Tea and biscuits is trollied around with dignity by a resident. Staff lay tables in dining room. 11.30 am A disorderly queue of wheelchairs and Zimmer frames straggles outside the loos: ‘Have you finished? Let’s wipe your bottom – good girl.’ 12 noon Residents in wheelchairs – the hares – are zoomed into the dining room. Then the tortoises – on Zimmer frames, tripods and sticks – begin their slow, inexorable journey, converging – sometimes colliding – upon the dining room. Food is dolloped onto plates and served at great speed by Care Assistants with unwashed hands. The ‘babies’ (i.e. the confused residents) are exhorted to eat: ‘Let’s play aeroplanes… watch’ – an overladen spoon weaves in the air to be thrust into a rejecting mouth. First of the residents put back to bed. The others restationed at their allotted seats. 2.00 pm Bread buttered for tea by resident. Staff tea break. More residents to bed. Trays set out for residents in bed. Tea break. Hares and tortoises to loos and dining room for tea. More residents to bed. 4.00 pm Repeat of 11.30 routine. Mrs B — who had a stroke two years ago and is robbed of speech — watches listlessly as cutlery clashes about her. She makes no protest when her jigsaw, ever half-finished, is removed. Trays whisked in to residents in bed. 8.00 pm Night staff on duty. Tea break. Grumbles that ‘all the heavy ones’ are, as usual, left for them to get into bed. Evening drinks and drugs rushed round: ‘Don’t sit and talk to them... you can do that when we collect the cups.’ Sighs of relief when Mrs L wheels herself to bed. Only Mrs D remains: ‘The care staff will soon wear her down. It usually takes them about two months. Then she’ll be put to bed much earlier.’ Staff tea break. Feet up. Telly on. 10.00 pm A resident’s buzzer thoughtlessly interrupts the late-night film. Eyebrows rise wearily. The Care Assistants respond in pairs to this and subsequent calls — an average of ten throughout the night (I suspect that staff answer calls together to escape more easily from the residents.) 12 midnight Close down of telly. Mrs D at last indicates her willingness to be put to bed. Discussion about the futility of staff training rudely interrupted by buzzer. That’ll be Mrs R. Let her wait.’ As one authority put it: ’Waiting in itself can be a punishment and an expression of power by the institution which makes you wait.’ 2.00 am Mrs M is dressing herself for the third time tonight and crossly demanding her hat and coat: ‘It’s shocking to be kept waiting like this at my age. I must go home at once. My son will be wondering where I am. I only came here for the flower show.’ 3.30 am Five sliced loaves – three white, two brown – buttered and put on the tables for breakfast. But no bread, marmalade, or sugar on the ‘babies’ table because they would start eating it before breakfast at eight – not surprising when they have been waiting for up to three hours for it. 4.45 am Begin to dress residents...