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.

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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.

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