David Oliver: What’s the verdict on personal health budgets?
BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5138 (Published 21 August 2019) Cite this as: BMJ 2019;366:l5138
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David Oliver writes "...without sufficient safeguards, people could use their money frivolously or buy substandard care from poorly regulated sources".
I would replace "could" with "will". I ran a rehabilitation unit for 25 years and it was far from unusual for patients and relatives to spend money inappropriately, even if they were given expert advice by physiotherapists and occupational therapists (to whom I would defer). Examples included stairlifts (when inevitable deterioration would render them rapidly useless), inappropriate wheelchairs, inappropriate house adaptations and flaky "cures". And this was with their own money. I don't think that the denial of personal health budgets is paternalistic, not least when money is short; it is simply a case of targeting limited resources under the control of experts . To invent the notion that there is a refusal to cede control is politically correct nonsense. If people wish to waste their own money that's up to them but, as Prof Oliver points out, if it's money from the state a payout that has not been used sensibly may deny others.
Competing interests: No competing interests
I had the privilege of working with the late Professor David Brandon in Cambridge when he was developing Personal Budgets, then called Direct Payments, with the first four participants (service users with disabilities). The success of his innovation required: all the care management skills of David and his wife Althea, participants knowing they had access to them 24/7 if any crisis arose, and building mutual trust and collaboration. The model was then researched in a poor London Borough.[1] To make personal budgets work takes advocacy skills and accurate mapping of local community assets.[2]
If future doctors are going to understand and implement Personal Budgets (a decision for national policy-makers) then they must be trained in both advocacy and asset-mapping. These are key skills for public health, so perhaps that is one place in the curriculum where students might be introduced to what the WHO might consider their "emancipatory potential"?
[1] Maglajlic R, Brandon D, Given D. Making direct payments a choice: a report on the research findings. Disability & Society 2000; 15: 99-113.
[2] Improvement & Development Agency. A glass half-full: how an asset approach can improve community health and well-being. IDeA, London, 2010 - now available online https://www.local.gov.uk/asset-approach-community-wellbeing-glass-half-full, accessed 22 August 2019).
Competing interests: No competing interests
Re: David Oliver: What’s the verdict on personal health budgets?
Editor
I thank Woody Caan and Andrew Bamji for their comments
The issue of personal health and budgets is one on which I have no clear personal view, hence my setting out the arguments on both sides and leaving the conclusions open ended.
With regard to doctors learning advocacy and asset mapping, I suspect General Practitioners would be the ones leading the way on working with patients on developing personal care and support plans. The GP training curriculum is already shorter than that for specialist medicine, despite the pivotal role of GPs as true expert generalists meaning they probably need a broader range of knowledge and skill than their hospital counterparts. And there are constant calls for them to "Know more about" or "have more skills in" X Y or Z. I wonder if the solution might be in Advanced Practitioners or Care Co-ordinators or a smaller group of GPs specifically trained in these skills. However, there is a wider focus on shared care, supported self management, care planning (including advance care planning for End of Life) in health policy and to deliver these in any kind of mainstream way both GPs, primary and community care nurses and their secondary care and mental health counterparts would need relevant skils either embdedded in standard training or more feasibly, built into to specialised training beyond that.
With regard to Andrew Bamji, I think the considerable movement led by health advocacy groups, patient charities, some practitioners and now embedded in the NHS 10 year plan, towards care planning in partnership with patients and families would say that the "experts" and expertise are with the patients with regard to their own condition, their own lives, their own priorities and that expertise should be given parity with that of the professionals. Paternalism and pedestals are Passe in this narrative.
However, as he re-iterated, every decision to spend a pound of public money on one intervention, support, potentially deprives another patient If you read the detailed guidance from NHS England on what Personal Health Budgets can be used for, they explicitly exclude medications, operations, procedures, GP appointments and urgent care. To my mind this is perhaps their biggest limitation. If you are living with one or more long term conditions which mean all of these things may be necessary then a personal budget cannot in reality cover all that person's needs even if it can allow some more personalised support.
David Oliver
Competing interests: No competing interests