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Barker Commission calls for ‘single’ health and social care system

The Barker Commission has called for a single health and social care system in England, with a “ring-fenced”, “singly commissioned” budget, and more closely aligned entitlements.

Drawing on accounts from patients and their families and a vast amount of research, the commission, put together by the King’s Fund, argues that the current system is “no longer fit for purpose” and says the two systems of health and social care rub against each other“like bones in an open fracture”.

In the study –‘A new settlement for health and social care’– which is an interim report before the final version is published in October – the commissioners claim that the root of the problem is a lack of alignment in funding, organisation and entitlement.

Key findings highlight that there is a problem of adequacy, with too little public money spent on social care and too much demanded of it at a time of rising needs. Additionally, the current system is heavily dependent on unpaid carers and is inequitable, with shifting boundaries on entitlements.

In the preface of the report, Kate Barker, chair of the commission on the Future of Health and Social Care in England, stated: “We set out the key criteria that we propose to use to assess the options which would move England towards this new settlement. Broadly, they consider transparency, equity, efficiency, the split between collective and individual responsibility and affordability. The evidence discussed here suggests that the present settlement fails on all of these criteria”

With regards to the problems of alignment and adequacy it raises the issue of affordability – how to fund the type of health and social care system fit for the 21st century.The broad options for raising extra resources include using existing health and social care resources more efficiently; raising more public funding; and increasing private funding.

On commissioning, the report notes: “[It is not our] intention to devise a new model commissioning system. In our view, it would not be productive for the country to get into a sterile debate about whether the NHS should take over the commissioning of health care or whether local authorities should be the commissioners of health. The advocates on either side will never be placated. We do note, however, that some, including the health select committee, have suggested that the nascent health and wellbeing boards, which bring health and social care together, might be the vehicle for that.”

In the report the concept of improving productivity has also been explored. It has been suggested that improvements in end-of-life care, better integration, and ensuring NHS money is spent on what is cost-effective should be explored – but this is considered insufficient to meet all the costs.

A number of potential policy implications have been raised by the report, such as proposals that should consider ‘harder’ long-term choices, including extending NHS charges, developing a health insurance market, and introducing a tax for health and social care.

Some of the funding options would be incredibly controversial in political terms, though some are also judged as less effective or likely to increase fragmentation rather than decrease it. The commission rejects a wholesale switch to classic social insurance model (as used in France and Germany), and says tax relief on private medical insurance is also a poor option.‘Patient passports’ – Conservative party policy in 2005, whereby patients would be able to take the average cost of their treatment in the NHS and spend it in the private sector, topping that up if need be to afford the cost of private sector care – are also dismissed.

In response to the interim study, Rob Webster, NHS Confederation chief executive, said: “With demographic changes impacting on social care as well as the NHS, and rising numbers of people needing long-term and ongoing support, our 2015 Challenge – calling for a frank and honest conversation between the public and politicians – applies equally to social care.

“There is now a consensus that joined up or ‘integrated’ services for health and social care are essential in the 21st century. This fits the needs of patients. A similar approach for health and social care finance could, in principle, help make this a reality.”

However, he concluded that there will be much to consider in taking this forward – from real term budget allocations for local government reducing by 14% in the last four years, to the balance of risk across the health and care system, and the issues of charging for social care versus free NHS care. These will need to be addressed if the NHS is to spearhead positive change towards a truly integrated health and care system.

These are the basic options investigated in the interim report to fund the proposals:

Option 1 (more efficient use of existing resources) via

1. Productivity (moving poorer performers closer to the best)
2. Shifting resources within health and social care to improve integration (though most evidence suggests integrated care improves outcomes and the patient experience without necessarily saving much money)
3. End-of-life care (optimised services outside hospital)
4. ‘Rationing’ (reducing or eliminating access to certain procedures and treatments – the commissioners reject this option for a range of reasons)

Option 2 (raising more private funding) via

1. New or extended NHS charges, as one element of a new settlement that better aligns entitlements in health and social care (e.g. remove or change blanket exemptions on prescription charges, charges to visit a GP, a charge for outpatient attendance, a charge for hospital stays or hospital treatment)
2. Develop an insurance market and other financial products
3. Provide tax relief on private medical insurance (‘lifting a burden’ from taxpayers as more people go private – the commissioners dislike this option)
4. A ‘patient passport’ (also dismissed)
5. Remove tax disincentives on health and wellbeing programmes (making more wellbeing programmes available in workplaces, for example)

Option 3 (more public finance) via

1. Introducing a hypothecated tax for health and social care (National Insurance plus alcohol and tobacco taxes raise nearly the same amount as public spending on health plus social care, for example – but the tax would not move in line with spending need)
2. A wholesale switch to classic social insurance (this, the most radical option in the whole report, is basically rejected)
3. Diverting existing benefits, such as Attendance Allowance, winter fuel allowance, free bus passes and concessionary travel, or free TV licences
4. Changes to the tax regime for pensions
5. Apply National Insurance to those working on past state pension age
6. Forgiveness of capital gains tax at death
7. Increase inheritance tax
8. Levies on death
9. Impose VAT on private health care

Norman Lamb, care and support minister, said: “The founding principle of the NHS is that it is free at the point of use. We are clear that it will continue to be so — this government doesn't support the introduction of charges for treatment or hospital stays. 

“We are already working to join up health and social care in this country. We have created a £3.8bn fund to bring local NHS and councils together, focusing on helping people to live independently, getting them out of hospital more quickly and preventing them from getting ill in the first place.” 

He added that the government’s reforms to the way people pay for care will make the social care system “fairer”, protecting everyone from catastrophic care costs. 

For more details on the Barker Commission’s report, including an interview with the commissioners, read the May/June 2014 edition of National Health Executive. Subscribe at www.nationalhealthexecutive.com/Subscribe

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