You know within moments of walking in. Not from any checklist or rating. Something in the quality of the light, the pace at which people move, whether the space smells of cleaning or of cooking. That felt sense is immediate and, across hundreds of environments in six countries, it has proven reliable:
Is this a facility, or is this a home?
I came to dementia care sideways. Not through clinical training or personal caregiving, but through a social art project that became True Doors — the simple idea of personalising the entrance to a resident's room with an image of a door that reflected a past home or current preference. That project took me into nursing homes across the Netherlands and eventually in six countries. True Doors has now completed projects in seventeen countries. Along the way, I hosted delegations from Hong Kong, Japan, Singapore, and Taiwan — people who wanted to understand what Dutch care innovation looked like from the outside. I began developing new solutions, providing consulting, and, for a period, volunteering. What I've been doing throughout it all, alongside everything else, has been observing.
I should say what I brought to that observation. My background before dementia care was in banking, market analysis, and language technology. I am accustomed to walking into organisations and reading them — their structures, their incentives, what their processes are actually designed to produce, regardless of what they say they are designed to produce. Dementia care, seen through that lens, is a sector with a structural problem that it has not yet found a way to name honestly.
The approach that works most effectively in dementia care is not complicated to describe. Small, human-scale environments. Well-resourced, well-trained staff working in self-steering teams with enough autonomy to respond to the person in front of them. A pace that belongs to the people living there rather than to the schedule of the people working there.
The evidence consistently points in this direction. Every care farm I have visited has had something of this quality. The best small homes do too. The problem is that this model is almost impossible to sustain economically at scale. Large homes exist not because they produce better outcomes but because the economics of care make them the only financially viable response to the cost structure. The sector knows this. It does not talk about it enough.
What the economics produce in practice is environments where the ratio of staff to residents makes genuine presence nearly impossible. Where task completion becomes the measure because it is the only thing that can be measured within the time available. Where the built environment — often badly lit, institutionally scaled, designed for operational efficiency — works against the very thing care is supposed to provide.
You feel all of this within moments of walking in.
Dementia care draws people who care. That is not a small thing — it is the sector's primary asset, and it is consistently undervalued in how organisations are structured and resourced.
The difficulty is that caring, sustained over time in under-resourced environments, moves toward exhaustion without adequate support. Moral distress — the gap between the care a person knows is right and the care the system allows them to give — is not an occasional experience for dementia care staff. It is extensively documented and a background condition of the work in most settings. High turnover is the visible consequence. What is less visible is what it costs the people who stay.
What makes the difference, when it exists, is rarely a programme or a policy. It is more often a specific person — sometimes an administrator, sometimes a team leader — who holds the connection between what is decided at the governance level and what lands in the room where a resident is being helped to dress in the morning. In the implementation literature, this function is sometimes called boundary spanning. In practice, it looks like someone who understands both the board's priorities and the realities of direct care, and who can translate between them without losing either. When that person exists, sustainable person-centred care becomes possible. When they don't, no amount of individual excellence by direct care staff compensates for long.
Organisational culture change efforts have understood this dynamic for decades. Their consistent challenge has been cost and portability — the question of whether models developed in particular cultural contexts travel to multicultural urban settings as their proponents suggest.
Six years ago, I wrote about the standards landscape across major Western care systems — the variance was striking then, and the gap between what was being measured and what person-centred care actually requires was wide. [That piece is here.] Progress since then has been real, if uneven.
In Western care sectors, standards are moving in the right direction, if slowly. For example, Australia's aged care reform, following its recent Royal Commission, produced a serious shift toward measuring dignity, identity, and choice alongside clinical safety indicators. Germany has been implementing outcomes-based measurement, away from purely process inspection.
Canada finalised substantial new long-term care standards through the Health Standards Organisation in 2023 — the content is genuinely rigorous — but the structural problem is that federal standards carry no binding authority, leaving provinces to retain jurisdiction over how care is actually regulated. The work has been done. The mechanism to require anyone to use it has not.
In the United States, the picture is the most complex. The sector delivers well for people who can afford private care and poorly for those who cannot. A federal staffing minimum introduced in 2024 moved things in the right direction, though later than it should have. The broader system remains market-driven, and access to good dementia care still aligns closely with what families can afford. That said, there are also rare examples of nonprofits, usually well-supported by their local community, that provide outstanding care.
Person-centred care has sometimes been treated as unmeasurable — something felt rather than assessed. That position is no longer defensible. Falls, pressure sores, and psychotropic medication use are easier to count. But the harder measurement is being done seriously in several national systems, and the tools are being developed.
What remains inconsistent is the political will to implement, enforce, and resource the care that good measurement would reveal as necessary. And what is absent entirely is international alignment — a shared framework that would make best practice portable across borders and reduce the dependence of care quality on the accident of national political cycles. Other sectors have been here before — food safety, building safety, aviation — and in each case the argument that international alignment was too complex or too politically difficult eventually gave way when the human cost of inconsistency became impossible to ignore. The frameworks for doing the same in dementia care already exist. What is missing is not architecture but will, and in the current political environment, with attention and budgets pulled elsewhere, that is unlikely to change soon. This is not a pessimistic conclusion. It is just our reality.
For a period, I volunteered at a local nursing home. Not consulting, not observing — simply being present with residents as part of the ordinary texture of the day. What the volunteering gave me was something that consulting, product development and research, for all their value, couldn't — direct and unhurried contact with residents without agenda or role.
There is a quality of authentic contact available in those moments — sometimes just a moment, a look, something exchanged without performance — that is genuinely rare. What passes between people in that space is direct and entirely real in a way that most human contact, managed and mediated as it is, rarely achieves. I encountered it repeatedly, in small moments, and it was among the most valuable things the work gave me.
Across most major Western care systems, the direction of policy is now toward ageing in place — supporting people to remain at home for longer, with care coming to them rather than them moving into residential settings. The logic is clear: most people want this, and the cost of institutional care at scale is becoming fiscally untenable as populations age. The Netherlands moved in this direction earlier than most, implementing significant long-term care reforms in 2015 that tightened nursing home admission criteria and shifted lower-acuity older people toward home-based support.
A decade on, the Dutch experience is instructive — and not only as a success story.
The reforms worked in their immediate aim. Nursing home admissions dropped sharply. Institutional expenditure reduced. District nursing expanded. But the implementation was abrupt, and the transitional costs were real. Municipalities suddenly responsible for a frailer population than they were resourced for. Waiting lists that grew rather than shortened in the early years. Budget cuts that accompanied the reform and were later — tacitly — partially reversed, as it became clear they had gone further than quality could absorb. The Dutch government reinvested significantly from 2021 onward, allocating over two billion euros to restore nursing home quality that the reform period had thinned.
The deeper structural issue did not resolve. Ageing in place redistributes where care happens — it does not reduce the total demand for care labour. In 2019, one in six Dutch workers was employed in health and long-term care. Projections suggest that maintaining current care levels will require something closer to one in three by 2060. No ageing in place policy changes that arithmetic. It shifts some of the burden onto district nurses, GPs, informal carers, and families — who absorb it without always being adequately resourced or recognised for doing so.
There is also an equity dimension that policy documents tend to understate. Ageing in place works well for people with strong informal support networks, adequate housing, and the cognitive and physical capacity to direct their own care. It works less well — sometimes poorly — for people who live alone, whose families are geographically dispersed, or whose decline is faster or less predictable. The population that benefits most from good residential care is often the population least well served by ageing in place as a default policy position.
Australia, Germany, Canada, and the UK are now moving in the same direction as the Netherlands did a decade ago, toward home and community-based care as the preferred, cost-managed model. Each will encounter some version of the same pressures. The workforce redistribution problem, informal carer burden, equity gaps, and the temptation to implement too quickly and cut too deeply in the name of fiscal reform. The Dutch experience is not a case against ageing in place. It points to implementing it gradually, genuinely resourcing the home care infrastructure, and being honest about what it asks of families and communities — rather than treating it as a policy solution that resolves the underlying economics of care. Unfortunately, it does not. It only changes the shape of the problem.
The questions that dementia care kept posing — what happens to people operating under continuous pressure without adequate restoration, what it costs an organisation when the gap between stated values and daily practice becomes structural, what allows some people to maintain genuine presence over time when the conditions work against it — were not only being observed professionally. They were being lived simultaneously, as many people navigating the middle of a full adult life are. That combination of observation and lived experience is where the parallel area of my more recent focus began — one concerned with how people sustain capacity, maintain judgment, and stay genuinely present across the changing conditions of midlife. The dementia care work continues. The questions it raised turned out to have a wider radius than the sector they first appeared in. I've begun sharing this newer area of work via The Capable Life Series.