Illustrated summary of the Barker Commission's final report

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Part of Commission on the Future of Health and Social Care in England

The final report from the independent Commission on the Future of Health and Social Care in England examines the current health and social care systems and proposes a new approach that redesigns care around individual needs. The commission has concluded that this vision for a health and care system fit for the 21st century is affordable and sustainable if a phased approach is taken and hard choices are taken about taxation.




Hospitals were given to the NHS. What we now call social care was left with local authorities.

This organisational structure persists to this day.



People are living longer with more complex diseases that require co-ordinated health and social care.

The distinction between health care and social care is being eroded by these changing needs and new ways of meeting them.

For better services, spending will have to increase and become more joined up. But how could this be done and where should the money come from?

The King’s Fund set up the independent Commission on the Future of Health and Social Care in England, led by Kate Barker, to explore these issues and to come up with recommendations.

Here we present the problems the commission identified and the changes it proposes.

Problem 1: the system is unfair

Hospital and care home

Most health care (major and minor) is free at the point of use. Social care is heavily rationed and means tested.

This leads to situations where people with dementia have to pay for their own care while people with cancer don’t. Both cases involve significant care needs but they get very different levels of assistance from the state. There is not equal treatment of equal needs.

Problem 2: the funding is separate

Marie speech bubble

The NHS budget is ring-fenced, comes mostly from national taxation and must be spent on health. Publicly funded social care is paid for by local authorities through a mixture of central government grant, council tax and user charges. Levels of spending vary across the country.

Deciding who pays for what is a constant source of friction which can impact on people who are caught between the two systems.

Problem 3: the system is not co-ordinated


The organisations that commission health and social care - 211 clinical commissioning groups for hospital care, emergency care, community care and mental health; 152 local authorities for social care; and NHS England for primary and specialist care - are not aligned.

This creates inefficiencies with financial and human costs. For example, 3,000 beds a day are occupied by people who are fit to leave but are stuck in hospital while funding or assessment is resolved.


The commission concluded that tinkering with the existing system is not enough to address these problems.

We need a new settlement for health and social care to meet 21st-century needs and aspirations.

What would this involve?

Change 1: commission health and social care together

Health and social care

Remove the barrier between health and social care. Have a single, ring-fenced budget and commission both together.

Change 2: create simpler pathways with more personal control

Doctor and patient

Design simpler pathways through the current system that respond to changing levels of need.

Use a new care and support allowance and personal budgets to give people more control over the support they receive.

Change 3: increase provision of ‘free’ social care

Critical to low needs

Make all social care for those with ‘critical’ needs free at the point of use.

Extend this to ‘substantial’ social care needs as the economy improves.

By 2025, provide support for ‘moderate’ needs as well.

These changes offer a big prize – a more integrated service, simpler pathways through it and more equal treatment of equal needs. But this has to be paid for somehow, either from the public purse or out of people’s own pockets.

This new settlement will be more efficient and achieve better outcomes for people – but it will cost more overall.

The hard choices: how should we pay for this?

How to pay for this

These changes should not be paid for by new NHS charges, nor should they be funded privately or through insurance.

Instead, this increased access to social care should be paid for by public finance, and much of the cost should be borne by those who can most afford it (wealthier people) and those who will benefit from it the most (older people).

How can we afford it?

Prescription charges

Make prescriptions much cheaper but remove most of the exemptions. Potential saving of £1 billion.

National Insurance

Restructure National Insurance to collect more from those over 40, those over state pension age and high earners. Potential extra revenue of £3.3 billion.

Contributions from older people

Limit Winter Fuel Payments and free TV licences to older people on low incomes. Potential saving of £1.4 billion.

Wealth and property taxes

Review taxes on wealth and consider reforms to inheritance tax, wealth transfer tax, capital gains, property tax, etc.

Overall, the government should assume that public spending on health and social care will increase from 9.6% to 11–12% by 2025. The commission believes that in the long run this is affordable and sustainable.

That sounds like a lot of extra money but it’s still less than other similar countries spend on health care alone.

Bar chart

What do you think?

  • About the new settlement the commission is proposing?
  • How it could be achieved?
  • How it should be paid for?

Tweet using #barkercomm or comment on Chris Ham's blog, Now is the time to create a combined health and social care system.

This is an abridged version of the final report. Download the full version, including all 12 recommendations.

Download from SlideShare


J erasmus

Comment date
04 September 2014
My farther has a small private pension which he pays tax on after all bills have been payed he has less than 100 to buy food etc he can not get any help on rent rates because of his health even if cost of priscription he would be unable to afford this becUse of previous job I am aware that some of people on pension top up as they pay no rent rates are able to go on at least 2 holidays a year these are people who did not put into pension funds


Comment date
04 September 2014
I am 74 and have two private pensions which I paid into for when I retire. I get a reduced state pension because I was in the RAF for fifteen years therefore did not meet the criterion for a full state pension. I pay over £1,000 a year in tax and £143.00 a month council tax. As I made provision for my retirement why should I be asked to pay more for my health care. I was healthy all my working life of 50 years and was diagnosed with Rheumatoid Arthritis in 2007. It is unlikely I will live until 100. It is a fact that as one gets older the body starts to fail, this will happen to the majority of people.


Comment date
05 September 2014
I think that many of us paid Income Tax & National Insurance for many years & just see it go into "one big pot" that is spent on a myriad of things and there is a perceived disconnect between what we pay and what we receive. The demarcation between NHS Care & Social Care is such an example.

I like the principle that money raised by National Insurance (NI) is regarded as Insurance and is spent on health & care services, unemployment & pension benefits. if we need more for these (in my opinion, essential) services then we increase NI contributions. However, these contributions need to be "ring-fenced" for these activities and not spent on other items or disappear into general government expenditure (including Defence, Foreign Aid, etc.)

As we aware that we could benefit from these NI contributions in the future, we would probably be more willing to pay them and they could be levied across the whole income spectrum, say as 12% of all sources of income. Avoidance should be minimised and no exemptions permitted - 12% at £25,000 pa and 12% at £250,000 pa and 12% on dividends, 12% on capital gains, 12% on selling your house (even the primary residence).

Eventually we will realise what we need & where it is spent, perceive the benefits and find that we can raise the money at say 10% or ....

edward Plumridge

Comment date
05 September 2014
If we scrapped 'the internal market' which was set up to privatise NHS services there would be a saving of £10,000,000,000 (ten billion pounds) or more according to some informed sources and the health professionals would all give a sigh of relief as the process is cumbersome wasteful and unproductive

Jon Morris

Comment date
05 September 2014
I agree that there is a need to bring social and medical care for the elderly together. However this needs to be done at a local not a national or regional scale. Patients are individuals they therefore need to be treated with a flexible and holistic response. Very large orgnaisations always seek to control and define a narrow range of "best value" responses. Thus patients get treated as a series of seperate problems, by a number of "experts" none of whom deal with the whole person. The experts are then expected to meet specific targets further disatancing them from actual care for the person.

Demnark decentralised its health service to put it mainly under local authoirty control with (according to various international bodies ) huge success. We should see waht we can learn from them. But it has to be real decentalisation not an NHS or central government seeking to retain control while in reality just dumping blame.


Comment date
06 September 2014
I find after years and years of discussion and reports, their repetative findings incredibly embarrassing to read. When I think of all the professionals and experts in the field that are simply incapable of ensuring radical change where it matters, on the ground, it becomes a real worry.
As a member of the public I find such endless findings, good as they may be, cast a very big shadow on the ability of managers and policy makers to actually manage the problem and importantly to 'bite the bullet' whilst all the while the public are suffering as this farce is endlessly rolled out.

Yvonne Adams

Comment date
06 September 2014
Having become disabled at 42 and given a company pension on medical grounds I have to pay for my means tested social care support as well as the preventative health care I need such as regular physiotherapy. The NHS is unwilling to pay for my physiotherapy because my conditions are "chronic". Consequently my husband has had to give up work to support me. Our financial "choices" are dominated by paying for the support and therapy I need!! I am only 55 now, so roll on the Care Act funding cap and a more integrated health and social care system.

Abdul Jaleel

Comment date
06 September 2014
As a retired NHS Consultant, I can recall numerous occasions when I saw the throw-away culture permitted staff to discard re-usable materials to be wasteful and occasionally damn negligent [they wouldn't this at home ].

I recently met the Chairman of hospital Trust in England where I worked for over 20 years and mentioned that people in his domain were leaving ALL lights on in the corridors and mini-nightingale wards for hours in summer day light even in these days of austerity , to which he shrugged his shoulders and said, "one cannot micromanage in the NHS "!

Susan Lomax

Comment date
08 September 2014
Mum was first diagnosed with dementia and so had to pay for all her care until all her hard won savings were gone. Then she was diagnosed with pancreatic cancer, for which all her care would have been paid. She didn't live long enough to benefit from that. Where is the logic? An illness is an illness, whether it's mental or physical. Dementia is a terminal illness and there is no cure. We need to support those affected, especially as a dementia " tsunami" is fast approaching.

mike lewis

Comment date
09 September 2014
stop sending money abroad to third word countries run by corrupt governments and start spending the money looking after our own people that have paid into the system all their life.

Beverley Taylor

Comment date
10 September 2014
This is the most sensible report I have read on health and social care for a long time.

I just worry about the implications for the viability of local government and local democracy when adult social care is given to health. What will be left for local government? It shouldn't stop the joining up health and care which is most needed, but it will have big implications for the future of local authorities.


Comment date
10 September 2014
Reducing the £5 billion in fraud by NHS employees and patients each year would go a long way to paying for these changes rather than increasing taxes.

Liam Hughes

Comment date
18 September 2014
Dementia is a neurological disease with profound medical and social repercussions. The costs of healthcare and social care for people with this condition should be met out of general taxation/ NI (as it is for many other conditions). We should reject any approaches which imply that services for people needing continuing health and social care are less important. Getting this right is an important mark of a civilised society.

Vimala Saraswathi

Comment date
28 September 2014
If some of the regulation on disposing the unused medication and all other things, is to be taken off. Let professionals use their common sense what to be disposed of what not to be, which can save a huge amount of money.
Not to give any aid to those countries where money is misused and fill the pockets of corrupt politician.
Try understand each other, wash away the Blame and Claim culture.

Louise Irvine

National Health Action Party
Comment date
31 October 2014
Where is your evidence of £5 billion of NHS fraud? If you are referring to the recent "report" about NHS fraud it was thoroughly discredited.

Louise Irvine

National Health Action Party
Comment date
31 October 2014
This is an excellent report in many ways. Its main recommendation - that personal social care be free and integrated with health care is good. Trying to work out what is health care and what is social care leads to a bureaucratic, time consuming process with illogical,, insensitive, inconsistent and often inhumane results that cause distress and delay for thousands of people needing care. Where I disagree with the report is the proposition that the money should be raised by means other than general taxation. General taxation is the most cost effective, progressive and easy to implement system for raising funding for public services. It does not make sense to me to say that older people who will be the main beneficiaries should pay more, because all of us (or most of us) will be old one day so we will all potentially benefit. The principle of general taxation funding is that there is pooling of resources and allocation to those most in need, when in need, with the wealthiest paying more. What's wrong with that? I would argue that we should not wait til 2025 to introduce free personal social care for those with even moderate needs. We should introduce that as soon as possible as, in the long run, it will save money by helping people remain independent for longer. And it would remove a significant layer of bureaucracy and facilitate joint commissioning as there would be no more time wasted on working out (or arguing about) who should pay for what bits.

Andy Ross

High Oak
Comment date
02 November 2014
Mike, cutting overseas aid is small beer and would end up costing us much more in disease control, emergency relief, refugees, defence, exports, lost influence etc

The Barker Report is a very sensible response with very sound economics, but I also believe there is a role for competition, though private sector should be used only as a bell weather

Cate Brunton-Green

Retired CHD Network Manager,
Comment date
15 July 2015
You are SO right Mike Lewis. Care within our own Country should be the first priority.

Dora Andrea Or…

Self employed,
Nao Support services for people
Comment date
23 March 2016
NHS waste is at its peak !
Staff and Providers / Commissioners of Services need to be held accountable
For waste and implement Good Practise based on Home Economics ( how they run their household !!
Consultants acquired personal wealth
And involvement in procurement of services via NHS needs rigorous assessment ..
I can write a whole chapter on waste for
Prescriptions not needed or repeated that are sent overseas for people that no longer live in the country ..
Pharmacists need to be held accountable
For every delivery they make etc ..
NHS can save billions on pounds via small changes and consideration of the products and services they use !!

uk national

Comment date
14 April 2016
any NI added to elderly should only be applied in steps after the earning threshold required to pay tax to pay tax. Any earning less than the tax threshold is not likely to have 12% available for NI after meeting bills etc.

There has been a lot of jealously about the retired receiving a free tv licence although of the 10 million retired, less than half a million are over the qualifying age of 75 years.

Regarding the winter fuel, I made two small changes and reduced my outgoings by £30 per month - more per year than the fuel allowance and something all ages, especially low income, would benefit from.

Education about healthcare, balance of fresh foods and budgeting should start at schools.

With regard to pensioner benefits who pay VAT, council tax and many, income tax, they would have worked and paid in to NI for 30-50 years. Consider those who have not yet done that many years and those under working age who have still to make a contribution but what they are receiving instead: dedicated maternity wards, midwives, pre and anti natal clinics, child support allowance, vouchers, a free baby pack upon arrival, play areas, leisure centres, sports fields and pools, reduced bus fare, reduced train fares, reduced air fares, tax free clothing, tax free books etc, 25p paid in to savings for any £1 saved by the saver to name but a few. The last point is good, however, remember that a pensioners savings have had their interest rate reduced from 8% per year several years ago to less than 0.5% now. A family with two children are paying less per head in council tax than a retired couple and using more of the services. It is not likely that any retired person would think the country is wrong to support able bodied people not working or working, working age people who cannot and also children, however, it would be misleading for me to say in this comment that the elderly have not and do not contribute or are getting any more financial benefits than anyone else.


Comment date
14 April 2016
you are right - supporting another person receiving medical care, a prescription for senakot is £7.50 whereas you can get it in any supermarket for £1.00. Same too with other over the counter products- the NHS would be paying far less than that but the profit is not being fed back in to the system to improve care.

There is no doubt that the medical people do an excellent job but they should look to modernise their approach to the running of it making better use of technology instead of trying to apply different ways to try to get the patient who is vulnerable to pay additional cash sums directly or indirectly.

Pearl baker

Independent Mental Health Advocate and Adviser/Carer,
Comment date
16 February 2017
It has been made too complicated, firstly there are no two peoples circumstances alike. Elderly Carers contribute greatly to the work force, we care for Grandchildren while the parents work (pay taxes) by them, we are providing FREE child Care, many of us are elderly Carers, too old to claim a Carers Allowance? we bring in TAXES for the Government by providing FREE childcare, we provide FREE Care and Support to Family members, saving the Government Billions.

Health and Social Care of course should be 'INTEGRATED' a CHC assessment should be carried out to determine what is the Health & Social Care needs of the patient.

The entire Population should have a Health & Social Care Budget (One) depending on Demographics and age, those in the Group of Continuing H&S Care will see the Budget increase.

The patient should be able to use their budget to improve their Health and Social Care, and 'shop' around for the service that best suits their needs.

I do NOT agree that Prescriptions charges should be increased for those in work or the elderly.

The majority of retired elderly still provide valuable FREE Childcare and Carers for other family members for FREE saving the Government Billions.

It is well overdue that the NHS put their own house in order by ensuring that GPs inform the Pharmacist when electronically prescribing the exact medication to Pharmacy, deleting and adding up to date Prescription.

I advocated many years ago that the Computer is underused. All should be linked to the GP and Community Service (CMT if you have one) if i required help support, i should be provided with a Link that i could use 24/7, this would be disseminated by the 'out of hours' link, and action taken, during working Hours you should be provided with 'key' worker link, cc to others in your 'Holistic' Health and Social care team, including the GP. Carers could be part of the Health & Social Care system, taking into account what they can do, and how they can contribute.

I have also seen a great Telephone for the Disabled large Key Pad, Photos above, contact number 'keyed' in. Press the button under the Photograph, this links in with the recommendations above.

Example: I suffered from a knee injury, visited the Pharmacist, referred to GP Surgery No Appointments, referred to Hospital, visit your GP if no better in two weeks, visited the GP now really suffering and a CARER. I think you need Physio, they are not busy, waited two months considerably worse, searched the Internet for Specialist in knees (Private) two days later met with Consultant, Scan straight after, two days later an injection into the knee, three days later 'out of pain' could walk. The £2300 it cost me was well spent.

I have not been to a GP for two years, and remain reasonably well. If i had a Health and Social Care Budget it would have increased in value? then i could pay again for my next treatment Privately.

Those unable to manage their Health & Social Care Budget would receive family, Advocate support.

I removed my 99 year old father-in-law from Hospital, he would have been dead within the week,now nicely settled, and looking good.

Those of us who live in large Houses when old, are often forced to remain there due to Caring for others within the family, we then pay Inheritance Tax up to 40% over the threshold, not much left to support those we have cared for all their lives, now we are going to pay another 5% Council Tax, and already living on a depleting Income and Savings.

As you can see we oldies save the Government Billions, without their support.It would be nice to get some appreciation once in a while for our FREE contribution to Society.


Comment date
23 July 2019

Because you should learn to be responsible for your own care. The taxes you've paid when you were working have already been used for your healthcare, roads, free education of your children. To burden the taxpayers now for your care in old age when you have assets that could definitely support your care would be an unjust enrichment at the expense of the younger generations who are struggling t even put up a deposit for a house. You will be taking away money that my children currently needs.


Comment date
23 July 2019

Any able bodied person with some intelligence can look after a person with dementia at home. They do not need specialist care from a specialist or consultant and specialist medical equipment that cancer patients needs. You could have looked after your mum as she's done when you were a child.


Comment date
23 July 2019

Plus the stupidity or staff causing solicitors to chase the Trust for compensation!

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