Do not judge on age But nor should people be judged on age alone, she says. To prove the point, she cites a story she has been told by a consultant geriatrician. ‘I always remember it. He had a lady in her seventies who was very disabled. He asked her who looked after her and she said her mother. He thought she had some cognitive impairment, but then he saw in the waiting room the 103-year-old mother. She was pushing her around in the wheelchair. ‘We have to be mindful of how ageing manifests in the individual. You can’t just judge on age, you have to react to need.’ So does that mean the focus of the past year has been wrong? ‘No,’ says Ms Garrett. ‘I’m not trying to detract from the real problems we have been hearing about and the need to address them. But my anxiety is that by consistently addressing the difficulties it is disempowering for older people and health staff. We are looking at ageing as a problem rather than something that is full of opportunities. ‘Unless you work in paediatrics or maternity, older people will be the patients you have most contact with, no doubt. We are all older people’s nurses now and so we should be helping them to achieve joy, a sense of wellbeing and a good later life. That has to be our ambition.’ Nick Triggle is a freelance writer NURSING OLDER PEOPLE

Should health and social care services be merged into a single budget? Charles Milligan

Some of this mental ill health is likely to be related to isolation and loneliness. Research for the Campaign to End Loneliness shows more than half of over-75s now live alone, with one in ten reporting they only have contact with family, friends and neighbours once a month. ‘Changing family patterns are having an impact,’ Ms Garrett says. ‘More and more people find themselves on their own, and I think we have a role in future-proofing our patients to help them prepare. ‘By this I mean talking to older patients about everything from their living arrangements and whether they need to move to a bedroom downstairs, to end of life care. It is not about scaremongering, but is just the reality.’

A commission’s advice that funding for these major services should be pooled has drawn support from some, but others need convincing, says Nick Triggle SINCE THE second world war, the NHS and social care have been run as separate, distinct services. One is free at the point of need and funded through a ring-fenced budget, while the other relies on means-testing and its budget is determined by local councils. But, according to an independent commission, the time has now come for that to end. The interim report of the Commission on the Future of Health and Social Care in England, set up by the King’s Fund, recommends a single, ring-fenced budget. The group – chaired by former Bank of England monetary policy committee member Kate Barker – says a combination of the ageing population and rise in conditions such as dementia has ‘blurred the lines’. This has been compounded by council cuts. Between 2008/09 and 2012/13 the number of people aged 65 and over reducing publicly funded care fell by one quarter, to just under 900,000. It has meant that there is an increasing amount of ‘friction’ over which sector is responsible for care, leading to delays or lack of support for patients, the commission says. ‘The current systems rub up against each other like bones in an open fracture,’ Ms Barker says.

But the report also leaves a number of questions hanging. On funding, aligning the sectors and deciding who should be in charge of commissioning, it is non-committal. Instead, the report makes a number of suggestions to kick-start a debate before the final report is published in September. These include introducing contributions for NHS care that could be capped, perhaps at £500 or £1,000 a year – similar to the social care reforms that start in 2016. Another option to consider, it says, is whether to provide free social care. It suggests this could be possible but limited to people with the most acute needs, such as those at the end of life or with advanced dementia. Of course, such steps are radical. But how is the underlying principle of a single budget being received? Royal College of Nursing long-term conditions adviser Amanda Cheesley thinks that a single budget could provide a solution to the problems, pointing out that cuts to social care have a direct effect on the NHS in the form of longer hospital stays and more frequent admissions. ‘If a pooled budget leads to better integration it would help prevent some of this, but that all depends on how imaginatively services are run,’ she says. ‘There is no point in robbing Peter to pay Paul.’ The NHS Confederation and the Local Government Association – bodies that represent NHS organisations and local councils – also say they are open to the idea. However, politicians still need some convincing. Shadow health secretary Andy Burnham has been pushing the option of a single budget, although the Labour Party has yet to adopt it as formal policy. Meanwhile, ministers stress they are already moving towards greater integration with the launch next April of the Better Care Fund, a pooled budget designed to encourage joint working. But that will amount to £3.8 billion compared with the £150 billion the commission estimates is spent on health and care once NHS, social care and private spending is added together. May 2014 | Volume 26 | Number 4

Nursing Older People 2014.26:9-9. Downloaded from by National University of Singapore on 11/21/15. For personal use only.


Should health and social care services be merged into a single budget?

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