-Older people in care homes are clinically complex and particularly vulnerable to the effects of poor care and poor medicine. They are also a group to whom the NHS seems least committed. Geriatricians have become disengaged over the past two decades, as a result of social policies rather than clinical judgements. In 2000, the Royal College of Physicians, with the Royal College of Nursing and the British Geriatrics Society, issued guidance and recommendations for improving clinical practice. This paper reports progress since then based on results of national surveys of geriatric medicine departments and primary care trusts in England. The results show that important deficiencies persist, though most respondents were in favour of greater specialist involvement. Some suggestions are made for ways to improve the shared care of residents in care homes.KEY WORDS: care homes, continuing care, comprehensive geriatric assessment, geriatricians, nursing homes, old age psychiatrists, older people, physician's role, specialist nursesIn 2007, there were over 350,000 people aged over 65 years resident in care homes in England. 1 There are three levels of care home provision. The first is 24-hour personal care assistance without nursing which is funded by local authorities, subject to means testing, here referred to as residential care homes. The second involves 24-hour access to qualified nursing care, where the NHS funds the nursing component. This group are here referred to as care homes with nursing. The third level of care home provision is NHS continuing care, which provides more complex or intensive nursing and/or other healthcare both within care homes and specially designated long-stay institutions. 2,3 People enter care homes for many reasons related to the loss of physiological, psychological, functional and social reserves. Guidance from the Royal College of Physicians (RCP), the Royal College of Nursing (RCN) and the British Geriatric Society (BGS) is that, before admission, an older person should be assessed for the presence of reversible factors, such as medical and rehabilitation needs, by a team including a physician skilled in geriatric medicine with the aim of preventing some of these placements. [4][5][6] This recommendation is supported by evidence of effectiveness. 7 Care home residents have ongoing and increasingly complex needs. 8,9 A recent national census of 751 care homes revealed that 72% of residents were immobile or required assistance to mobilise, 86% had one or more diagnoses explaining the need for personal care, 54% of care need was related to dementia, stroke or Parkinsonism, and 24% had the 'unholy trinity' of confusion, immobility and incontinence. 10 General practitioners (GPs) have principle responsibility for the medical care of care home residents and it has a major impact on their workload. 11 Less than 40% of GPs have had specialist training in the health and social care needs of older people. 12 NHS clinical input, as well as funding, should be appropriate to the level of ne...