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Vidhya Alakeson and David Coyle: Personal health budgets

12 Oct, 11 | by BMJ Group

Vidhya AlakesonDavid Coyle

Last week the Secretary of State for Health announced that from 2014 onwards, all individuals receiving continuing healthcare will be entitled to take control of that support through a personal health budget. Based on figures for 2009/10, that’s more than 50,000 people. The government has made no secret of its commitment to personal health budgets for the management of long term conditions in the NHS. Giving individuals greater control of everything from special education to health and social care is very much in keeping with its vision for public services as set out in the open public services white paper this summer.  But for clinicians who have been trained in evidence-based practice, Lansley’s announcement is arguably controversial. The national evaluation of the personal health budgets pilot programme will not produce its final report for another year. The NHS Confederation, for example, has been vocal in criticising the push for personal health budgets without good evidence as inappropriate. So is the Secretary of State’s haste justified?

There are three main reasons why continuing healthcare is the most obvious place to start for the roll out of personal health budgets. First and most practically, it is the easiest place to start. Personal health budgets involve giving individuals and their families control over an allocation of NHS resources that is paid directly to them or held on their behalf. They can use those resources to plan how best to meet their needs for care and support drawing on the expertise of clinical staff, third sector organisations, peers and family members. In many areas of the NHS, figuring out how much money should be allocated to each individual is tricky. If you’re receiving support from a community mental health team, for example, what proportion of the team’s salaries should be allocated to you? Continuing healthcare, on the other hand, is already based on individual packages of support which can be easily converted into a personal health budget.

Second, there is already some good evidence to support personal health budgets in continuing healthcare. Five pilot sites implementing personal health budgets for continuing healthcare report average savings of 20% compared to existing care packages. Savings come largely from the use of personal assistants to provide nursing care such as changing wound dressings rather than district nursing services and the direct employment of personal assistants instead of agency workers. Given these efficiency savings, some sites were putting pressure on the department of health to allow roll out even before Lansley’s announcement. Satisfaction levels among individuals and their families is also high. As one family member in Doncaster whose father received a personal health budget for continuing healthcare said, “the personal health budget worked well for me because I felt in control. Previously it felt as if care was ‘done to us.’ A personal health budget made dad and I feel as though we were valued participants.”

Third and most importantly, many families have been campaigning for the roll out of personal health budgets because too many get caught in the artificial divide between health and social care. For example, one mother whose son has Batten’s disease, a terminal, degenerative disease, found herself in the horrific position of having to disband the team she had recruited that had worked with her son for six years under a social care direct payment because her son turned eighteen and qualified for NHS continuing healthcare. As soon as he did, she no longer had the right to control his care through a direct payment. If personal health budgets for continuing healthcare had existed in her area, she could have moved seamlessly from one funding stream to another, changing nothing else. 

The case for rolling out personal health budgets will not be as cut and dried across all areas of the NHS as it is in continuing healthcare. Resistance to individual control will no doubt be greater in areas such as mental health, substance misuse, and dementia. Only 28% of mental health clinicians across all disciplines said that they were enthusiastic about personal health budgets. More significantly, most clinicians surveyed were not aware of what a personal health budget is or what it is for. NHS staff will be central to the success or otherwise of personal health budgets. While the policy drive may come from central government, successful implementation will be down to the hands-on workforce. Even with the statutory force of targets in social care, tokenistic practice in the implementation of personal budgets continued. But reticence has little to do with deliberate sabotage by staff and is most likely the result of ignorance and fear. These can be addressed through thoughtful support, training, and personal experience of the positive impacts of personal health budgets on people’s lives.

If the government wants to keep matching its rhetoric on personalisation with the day to day reality of individual control in the NHS, it will need greater engagement with clinicians, including commissioning groups, to shape the ongoing implementation of personal health budgets, irrespective of what the evaluation says.

Vidhya Alakeson
 works as an independent consultant focusing on a range of policy and implementation projects related to mental health, personalisation in public services and personal health budgets. She currently co-leads the national learning set for personal health budgets for mental health supported by the Department of Health and the NHS Confederation. She writes and presents regularly on personalization and personal health budgets.

David Coyle is a senior lecturer in mental health studies in the Faculty of Health and Social Care at the University of Chester. His research is mostly evaluating schemes and pilots implementing personal budgets within the North West of UK.

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