Don’t duck the hard choices spelt out by the Barker Commission

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The post-war settlement that created the current divide between health and social care must be replaced. That is the clear conclusion of the interim report of the Barker Commission published last week.

The commission argues that a new settlement is needed, based on a single, ring-fenced budget for health and social care in which entitlements to care are more closely aligned. Additional funding will be required to achieve this objective and hard choices have to be faced about where this should come from.

Headline writers claimed that the range of options for paying for a new settlement set out in the report (outlined below), spelt the end of a free-at-the-point-of-use NHS, echoing reports a few days earlier on a report from Reform on NHS funding.

In fact, the commission makes no recommendations on funding, other than arguing for a single ring-fenced budget for health and social care with adequate funding. In putting forward this argument, it demonstrates that health and social care are not unaffordable while also recognising the scope for using existing resources more efficiently.

At the same time, the commission is clear that social care is already facing a crisis in funding and the NHS is rapidly approaching one. Although implementation of Dilnot’s proposals will put a welcome cap on the amount people will have to pay for social care, cuts in grants to local authorities mean that far fewer people are receiving publicly funded care.

These issues have a direct impact on people who rely on health and social care at times of need. The commission’s report includes powerful reminders of this in the testimonies of their experts by experience.

One of these experts, Dominic Stenning, explained at the report’s launch why the status quo is not an option. His eloquent contribution was echoed by Guardian journalist, Jackie Ashley, whose brilliant analysis of the commission’s report drew on patient stories to show that fragmented care results in scarce resources being used inefficiently.

In an ageing society with an increasing number of people requiring both health and social care, few questions are more important than how to ensure funding is adequate and services are aligned. The hard questions asked by the commission include:

  • Should other areas of public spending be cut and resources reallocated to health and social care, for example, universal benefits for more affluent pensioners?
  • Should taxes be raised to bring in more resources to fund a new settlement, for example, through changes to rules on inheritance tax or by imposing VAT on private health care?
  • Should there be a hypothecated tax for health and social care?
  • Should charges be extended or increased for some NHS services in order to reduce the costs of social care met by people receiving this care?
  • Should there be a bigger role for social insurance, accepting that the commission does not favour a wholesale switch to this method of funding?

There is never an ideal time to ask fundamental questions such as these, and the period ahead of a general election poses particular challenges for politicians. But these questions are too urgent to wait until after the election – the next government will need to be in a position to act as soon as it takes up office. And if critics of the commission misrepresent its report as a neoliberal solution, then an informed debate about the options is much less likely.

To argue, as I’ve heard politicians across the spectrum do, that talk of alternatives will reduce pressure on the NHS and councils to become more efficient ignores the huge efforts being made to do precisely this. It also ignores growing evidence of the difficulties facing the NHS, which we will be analysing in greater detail in a forthcoming report. For many, the transfer of resources from the NHS to social care required by the Better Care Fund will only add to these difficulties.

If we duck the hard choices laid out by the commission, then services will progressively deteriorate with patients, users and carers the real losers. The King’s Fund will be supporting the commission in keeping the debate going in coming weeks and months ahead of their final report in September. We hope you will contribute by responding to the commission’s call for evidence and will hold politicians to account by supporting the case for change.


Howard Catton

Head of Policy and International Affairs,
Comment date
10 April 2014
What ever we do lets keep it simple - nurses curently spend lots of time dealing with continuing heath care assessments and certainly dont want more admin/bureaucracy created for clinicans if means and non means tested systems are brought together - a new system must create more time for direct care could be a helpful principle

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