A single budget for the NHS and social care – Barker Commission

A radical reshaping of how health and social care is funded and delivered in England is essential, according to an independent commission established by the King’s Fund, with a single budget for the NHS and social care, new funding streams and changes to prescription charges, and more free care for those who need it. 

The final report of the Commission, chaired by Dame Kate Barker, has called for a new approach that ‘redesigns’ care around individual needs regardless of diagnosis, with greater support provided to those nearer end of life. 

Within the ‘A new settlement for health and social care’ report it has been recommended that there should be a single, ring-fenced budget for the NHS and social care, with a single commissioner for local services. Currently the NHS is free at the point of need, while payment for care homes and home support is means-tested. 

NHS Continuing Healthcare – currently free – would in effect be merged with the wider social care system, under its recommendations. Those with social care needs assessed as ‘critical’ would get free social care. As the economy improves, free social care should be extended to those whose needs are currently defined as ‘substantial’, the Commission recommends. 

After “careful consideration”, the Commission rejected extending charges for NHS services, with the exception of prescription charges. Instead, to pay for these changes, the report argues that the bulk of the additional funding should come from the public purse, with wealthier people and older generations – the main beneficiaries of the changes – contributing more. 

For instance, radical changes to prescription payments include reducing charges, currently £8.05 per item, to as low as £2.50 – but significantly cutting the number of prescriptions exempt from charges to raise £1bn a year; limiting free TV licences and the winter fuel payment for older people to those on pension credit; and requiring people working past state pension age to pay National Insurance at a rate of 6%. 

The report also recommends that a review of wealth and property taxation should be undertaken to raise additional funds. 

Free social care 

In response to the call for ‘free’ social care, the Association of Directors of Adult Social Services (ADASS) said that there is 'no doubt' that creating a more coherent payment structure would serve to remove some of the barriers to a more integrated approach. 

ADASS president David Pearson said: “We must, however, make sure that there is sufficient funding in the first place: a free system that is poorly funded may well serve to create no more than an illusion of progress. 

“This report lands at a crossroads for public services and expenditure with the impetus to meet rising needs, falling resources and a desire to see a more integrated, personalised system coming to the fore. Thank you to the Barker Commission for highlighting the issues and prompting the debate.” 

The Commission has also recommended integrating Attendance Allowance, the benefit paid to older people with care and support needs (which would be renamed Care and Support Allowance), within the single budget for health and social care. 

Dame Kate, chair of the Commission said: “Our challenge was to look at the big and difficult questions about the kind of care system, and indeed what kind of society we wish for ourselves and our families. 

“The prize, if this kind of change can be achieved, is huge – a more integrated service, a simpler path through it, more equal treatment for equal need, a better experience for people who need care and their families.” 

Finding the funding 

Although mounting funding pressures are being faced in both the NHS and social care, the Commission’s report challenges politicians to look beyond the deficit and engage the public in a debate about future care and how it will be funded. 

For instance, the Commission calls on the government to plan on the assumption that public spending on health and social care combined will rise to between 11 and 12% of GDP by 2025. These levels will be broadly comparable to current expenditure on health alone in many other countries, it argues. 

In response to the report, a Department of Health spokesperson told NHE: “We agree that health and social care services should be more joined up – our £3.8bn Better Care Fund is making this a reality for the time ever, bringing NHS and social care teams together to help people live independently for as long as possible. We are also transforming the way people pay for the care they need, capping the amount they have to pay and providing more financial help. 

“We have taken tough economic decisions to support social care services and protect the NHS budget, which we have increased by £12.7bn since 2010.” 

Broadly welcoming the report, NHS Confederation chief executive Rob Webster said the Commission has outlined in absolute clarity how we might move to solve some of the challenges facing the NHS. 

“While we might not agree with all the recommendations it puts forwards, we welcome its contribution to that debate,” he said. “We know the impact funding and demographic pressures have on health and social care, and this report highlights the funding gap that is likely to exist in both budgets in the future.” 

Professor Chris Ham, chief executive of The King’s Fund said the proposals may not appeal to politicians, fearful of commitments of greater public expenditure, but these issues cannot simply be ignored. The Commission is clear – there is no ‘do nothing’ option. 

Shadow health secretary Andy Burnham added that the stark truth is “if social care is allowed to continue to collapse, it will drag down the rest of the NHS. This is precisely what is happening under this government”. 

NHE interviewed Commission member Professor Julian Le Grand about its work earlier this year, when the interim report was released. That interview is here: ‘I don’t think we should be deterred in any way by worrying about the political reaction’

Tell us what you think – have your say below or email [email protected]


Caroline Molloy   04/09/2014 at 16:30

It's not quite correct to say that 'the commission rejected extending NHS charges, with the exception of prescription charges'. In fact there are some charging suggestions that would set very worrying precedents hidden in the report. See analysis here

NHE   04/09/2014 at 17:15

Hi Caroline, that's a fair point - though we do mention NHS Continuing Healthcare further down the story, and in our blog on the issue: Yours is an interesting analysis, though perhaps a little unfair as regards the Commissioner's motivations: they seem to us to be seeking politically feasible ways of reducing the fragmentation of services for those stuck between health and social care, not just seeking ways of raising money from sick people. They quite explicitly reject, both in the interim report and here, many of the most regressive suggestions that exist out there for reforming health and social care. If this report really were a figleaf for an ideologically-motivated undermining of the principle of a free NHS, you'd have thought they'd have made a better go of it! They do reject a simple extension of the 'free' principle to all of social care as completely unfeasible/unviable, when really it is just another question of political will, and in many ways less controversial than some of the other options they explore (albeit that were rejected, such as a wholesale shift to a social insurance model, 'patient passport', etc). I'd have liked to have seen more on this aspect.

Dialysis Reliant   06/09/2014 at 09:30

If I have enough money to pay towards it will my dialysis (to keep me alive) become means tested in due course? If so will I still be able to pay my rent and be able to buy food and pay for fuel to get to my dialysis sessions ...or will the means testing bring me down to the national safety net level of about £100 per week after rent ?

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