Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: What’s the verdict on personal health budgets?

BMJ 2019; 366 doi: (Published 21 August 2019) Cite this as: BMJ 2019;366:l5138
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

A key component of the NHS long term plan was a set of commitments on personalised care.1 These included a target for 200 000 people to benefit from personal health budgets by 2023-24. The current number is around 40 000.2

This raises questions. For instance, will these budgets benefit the right people? Will they introduce risks or bring opportunity costs for other service users? Are they a cost effective use of scarce public resources, or would the money be better spent elsewhere? Are any safeguards required?

In England, personal budgets3 and direct payments linked to personalised care plans have existed in social care for some time. Their introduction was partly a response to care that was often depersonalising, paternalistic, and unable to give disabled people the choice and control they wanted.45 The Care Act 2014 made personal care budgets mandatory for all eligible recipients.67 Unlike the NHS, English social care remains means tested and based on eligibility criteria, not free at the point of care and based on need.8 Around a quarter of all social care spending on home based adult care is through direct payments.9

There’s no shortage of positive personal stories from recipients of personal health or care budgets, or from their parents or carers.10 Many say that it’s helped transform their lives and care, giving them back more control.11 Some healthcare professionals have a very positive view of the potential to revolutionise how they offer treatment, care, and support, helping to make care plans a reality.12

NHS England plans to build formal evaluation into its expansion plan for personal health budgets.13 But we already have intelligence from earlier multicentre pilots and personal budget evaluations, summarised by the University of Kent’s Personal Social Services Research Unit.1415 And the National Audit Office reported on personal care budgets in 2016.16 Its conclusions were mixed, showing that care budgets could improve the holder’s experience and save money, but they sometimes increased costs when compared with usual care and were hard for local authorities to administer. It concluded that any benefits were likely to come from improved outcomes for service users and not from any savings.

Critics question whether it’s prudent to spend parts of the NHS budget on relatively poorly evidenced models of support when we’re systematically failing to provide well proven services. Some fear that the move towards giving money to individuals is ideologically driven and represents further fragmentation and stealth privatisation of public services, using more consumerist approaches.171819

There’s also concern that direct payments may leave already vulnerable people with heavy responsibility that may add to their stress, especially without adequate professional support.20 And, without sufficient safeguards, people could use their money frivolously or buy substandard care from poorly regulated sources that put them at risk.21 Advocates see these issues as a paternalistic failure to cede control.1012

Me? I don’t think that personal budgets in health and social care, or newer integrated budgets covering both, will be the norm for most service users anytime soon.7 I’m less interested in ideology and more concerned about pragmatic, transparent evidence on the value they offer users, coming from scarce public resources—and about the implications and costs for other users needing health and social care.

What do readers think?



View Abstract