Intended for healthcare professionals


Let patients control the purse strings

BMJ 2008; 336 doi: (Published 10 April 2008) Cite this as: BMJ 2008;336:807
  1. Vidhya Alakeson, Harkness fellow in healthcare policy
  1. 1Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, Humphrey Building, 200 Independence Avenue SW, Washington, DC 20201, USA
  1. vidhya.alakeson{at}
  • Accepted 29 January 2008

Patient choice is much talked about in the NHS and other health systems but action has been limited. Vidhya Alakeson argues that piloting individual healthcare budgets would signal real commitment to creating patient centred care

As the burden of disease shifts from acute to chronic care, governments are having to reshape health services. The UK health white paper, Our Health, Our Care, Our Say, published in January 2006, outlines four goals: greater prevention and early intervention, more choice and a louder voice for patients, more support for people with long term needs, and tackling inequalities. Other countries in the Organisation for Economic Cooperation and Development have stated similar objectives. If governments are serious about these aims, they would do well to learn from recent innovation in social care. In the United Kingdom, the Netherlands, the United States, and Germany, the delivery of social care services is being transformed through the introduction of individualised funding mechanisms, such as direct payments and individual budgets. These mechanisms allow services to be more accurately tailored to individual needs and could particularly benefit patients needing long term health care.

UK social care experience

The UK introduced direct payments for social care in 1996 for disabled adults above the age of 16 years, elderly people, and carers of disabled children.1 The value of a direct payment can vary from a few thousand pounds to over one hundred thousand pounds depending on the severity of the person’s needs.2 Thirteen local authorities are piloting individual budgets, which go a step further towards integrating support for people needing long term care by combining six different funding streams into one budget, with the exception of NHS funding.3

Direct payments and individual budgets operate slightly differently, but the basic approach is the same: instead of receiving services organised and provided by …

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