Do personal health budgets lead to better care choices?BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d6532 (Published 11 October 2011) Cite this as: BMJ 2011;343:d6532
Last week, England’s health secretary Andrew Lansley announced that 53 000 people with ongoing complex health and care needs would be the first group to become eligible for personal health budgets from April 2014.
The announcement was accompanied by the caveat “subject to evaluation of the pilot programme,” which runs until October 2012, and the disclaimer that the health secretary was responding to the NHS Future Forum choice and competition report in June. This backed the introduction of personal health budgets for patients with complex needs and urged the government to spell out its intentions for the policy.
But according to Karen Jones, a research fellow at the University of Kent who is leading the evaluation of personal health budgets, the government’s intentions have never been in any doubt.
“In all the conversations I’ve had with the Department of Health, there was always going to be a roll out. They were waiting for the evidence to guide policy, explore the best methods to use, and for which groups,” she explains.
Personal health budgets enable holders to purchase services of their choosing either directly or through a third party, with the ultimate aim of boosting health outcomes. The government also hopes they will prompt more integrated care and cut overall costs.
Since the coalition came to power, personal health budgets have featured regularly in key health and social care policy documents, including the public services white paper in July.
As care services minister Paul Burstow put it in July 2010, “In so many ways, personal budgets encapsulate what we represent. Our single radical aim: to change the relationship between the citizen and the state. To do less to people, and more with them.”
That means a fundamental change in the doctor-patient relationship, suggests Richard Humphries, senior fellow at health think tank the King’s Fund.
“It’s not just about giving people a pot of money, allowing them to behave like consumers, and letting them get on with it,” he says. “If the aim is to personalise care, it’s as much about changing the culture and the relationship with healthcare professionals.”
Research for the NHS Confederation on the views of mental health service users and carers on personal health budgets, indicated enormous support among doctors for the need to involve patients in their treatment. “But most of them thought they were doing it anyway,” says Jonty Roland, senior policy researcher. “That wasn’t the view of service users.”
Hardly any doctors have participated in the pilots, which started in 2009. “When we interviewed organisational representatives three months in, they were concerned no doctors were involved,” says Dr Jones, adding that the evaluation intends to revisit this.
Julia Sinclair, senior lecturer in psychiatry at the University of Southampton, became involved in a pilot of personal health budgets for alcohol misusers more by chance than design, but she is now an enthusiast.
“I do think it’s exciting and that it could improve outcomes and make different services work together. And I think it will create options and engage providers. So I am a convert to it, and I am not easily converted,” she declares.
But international expert on personal health budgets, Vidhya Alakeson, now research and strategy director of think tank, the Resolution Foundation, says that while “seeing has been believing,” the Department of Health has devoted little resource to convincing clinicians of the merit of personal health budgets. “This has got to shift for [personalisation] to have legs,” she contends.
“Clinicians do need to be engaged. A nominal target for clinical commissioning groups would be helpful, so it’s on the page and not just a notion,” ventures Greg Rogers, East Kent general practice champion for personal health budgets. “This is cheap medicine that makes a big difference. But it’s a really tricky thing to put in a new culture and a new way of thinking.”
He became a believer after working on personal care planning, as part of the government’s quality, innovation, productivity, and prevention (QIPP) agenda. A personal care plan, which puts patients in the driving seat, is at the heart of a personal health budget. “When patients take responsibility and achieve what they want to, by and large, outcomes are better,” he says.
While attendance at his talks has been good, and the testimonies of budget holders persuasive, general practitioners (GPs) have been thin on the ground. But more through overwork and uncertainty about the future, as a result of the impending healthcare reforms, than disinterest, he thinks.
“There is so much change at the moment, people don’t know which policy is going to stay the course,” he explains. “And there are so many nuts and bolts to get straight first, that GPs have delegated [personal health budgets].” But he’s not unduly worried.
“GPs are important in that they need to signpost patients to personal health budgets, but they aren’t necessarily key,” says Dr Rogers. But external brokers who are trained in motivational interviewing techniques—which GPs are not—and who, crucially, would be on a more equal footing with the patient, are, he suggests. The snag is cost and capacity.
“The big hope is that the third sector will step forward with trained accredited workers who will then have the capacity to get involved with long term conditions,” he says, adding: “Brokerage could be part of a charity’s steady income.”
Without it, there’s the potential for personal health budgets to widen health inequalities, he says. “To advocate for those without the intellectual or social capabilities, and to provide ongoing support is a must,” he emphasises. “It would be utterly wrong if only the intelligent and those who know how to navigate the system got personal budgets.”
The 61 pilots, which involve 2700 people across England, focus mostly on long term conditions, continuing care, end of life care, and mental health, with one or two sites covering maternity services and substance misuse. Twenty are being evaluated in depth.
But, explains Ms Alakeson, “A lot of sites didn’t want to take on the kinds of services that could be included in personal health budgets. They didn’t want to have power fights with providers. So what individuals have control over is what would least disturb the NHS—support services. Lots of clinical services have been excluded.”
She also questions the research methodology, which is based on controlled trials and not suitable for the task in hand, she suggests. “I don’t hold out much hope for the evaluation, and it won’t give us as much evidence as we would like,” she claims. “Anecdotal evidence from the pilots shows that [personal budgets] improve health outcomes, but we don’t have anything systematic or rigorous.”
Personal budgets for health and social care were introduced more than a decade ago and are used in North America, Australasia, Scandinavia, and much of Western Europe. Yet a 2010 review of international evidence by the Health Foundation found little empirical research and clear gaps around evidence of the effect of personal budgets on health outcomes and cost effectiveness.
A 2011 report by the Health Services Management Centre at the University of Birmingham acknowledges that the evidence is “limited” but argues that it is nevertheless “promising.”
Evaluation of the individual budget pilots in social care, which ran in 13 English local authorities in 2005-7, showed they were cost effective but no cheaper than conventional care.
But the Centre for Welfare Reform’s Active Patient, which includes evaluations of UK and US self directed social care programmes, claims “the potential for improvements in health and in efficiency within the NHS is clear.” It cites as examples the use of personal budgets in prevention, residential care, and out of area placements and better integration between social and NHS continuing care.
And current and would-be users like the concept. But the choices that some budget holders have opted for have prompted concerns about the evidence for their effectiveness and whether the outlay can be justified when money is tight.
“Should we be spending taxpayers’ money in cash strapped systems on gardening or aromatherapy that may make people feel better, but for which there is no evidence that it actually makes them better?” asks Royal College of General Practitioners chair, Clare Gerada.
“There is a lot of resistance among clinicians to spending money on non-evidence based treatments, but when you talk to service users that is almost the first thing they suggest, because they want to demedicalise their care,” argues Mr Roland. “A lot of healthcare doesn’t look like healthcare anymore; it’s about helping people have a good life.”
Nevertheless, the “pick ‘n’ mix” potential of personal budgets has sparked alarm about the effect of competition on existing services, amid fears that personalisation may be a Trojan horse for privatisation.
“The concern is how the development of smaller providers would undermine existing services on which the majority of the population depend,” says Richard Vautrey, deputy chair of the BMA’s GP committee. “We need to be careful that [this policy] doesn’t destabilise those services,” he adds.
Ian Mulheirn, director of think tank the Social Market Foundation, believes that some level of coordination will be needed to allow economies of scale while still enabling choice. “The pure market approach is that choice is a market force for improvement. But commissioners need to shape it in a thoughtful way,” which means carefully and incrementally, and by targeting those who would benefit most, he explains.
“[Personalisation] is not even a Trojan horse, it’s a pretty blatant attempt to shake up the supply side,” he adds, but warns: “If measures are not in place to liberalise [this], we won’t get the efficiency improvements, which in theory, are available.”
Mo Poultney is a personal health budget broker in alcohol services for Southampton City Primary Care Trust. Her job is to stimulate the market so that eligible patients can choose whether to buy in support services to detox at home or opt for a residential facility.
Previously, the four local residential providers offered detox only as part of an expensive 12 week rehabilitation package, but thanks to the removal of the block contract to fund personal health budgets, they now offer stand alone detox and other services clients say they want, says Ms Poultney.
“At first lots of providers didn’t want to know, because they liked the safety of the block contract,” she explains. “But what persuaded them was that the NHS didn’t have the money it used to, and they realised they needed to start offering something different rather than get no money at all.”
How and where to lever money out of the system to pay for them, with no extra funds, is just one of several logistical hurdles that personal health budgets face. Others include how to apportion unit costs of care, join them up with personal budgets in social care, and regulate a proliferating market of small providers.
Alison Austin, personal health budget lead at the Department of Health, is confident that the existing regulatory frameworks will be sufficient. “I can’t see there being a separate body, because after all this is NHS money. But it’s about risk proportionality and people being able to make decisions about who provides services for them, which they do all the time,” she says.
“You’ve got to have some standards. But if you apply lots of controls, you build in protection but you lose innovation,” agrees Mr Humphries. It’s about getting the balance right.”
Personal health budgets
A personal health budget is a sum of money allocated from NHS and social care funds to meet an individual’s identified health and wellbeing needs and agreed health outcomes. These are set out in a care plan along with how the money will be spent, and the plan is signed off by the primary care trust or clinical commissioning group.
Personal budgets exclude emergency care and core general practice services. They cannot be used for alcohol, tobacco, gambling, debt repayment, or anything illegal. But otherwise, there are few restrictions on the goods and services to which they can apply.
Budgets can be disbursed:
As a notional budget, where the NHS holds the money and buys or provides the goods or services chosen by the patient
Through a third party independent of the NHS
As a direct payment—currently only available for patients participating in the national pilot.
Holders are not entitled to additional or more expensive services, or preferential access; nor can they “top-up” the sum from private funds.
For more information see www.personalhealthbudgets.dh.gov.uk
Cite this as: BMJ 2011;343:d6532
Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from her) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.