In a speech in July 2010, Paul Burstow, Minister of State for Care Services, described them as the embodiment of what the government aims to achieve: '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.'
This enthusiasm is shared by the Secretary of State, Andrew Lansley, who recently announced his intention to roll out personal health budgets to all those receiving NHS continuing care by April 2014 and ultimately to a wider range of patients. Personalisation will be achieved by enabling patients to make their own decisions about how to spend the NHS funds allocated to their care.
It's an attractive vision, but is budget-holding – with its related complexities and risks to the budget holder – the best way to achieve greater responsiveness to individual needs? The fourth interim report from the Personal Health Budgets Evaluation may sound some alarm bells.
The evaluation team's latest report covers the early experience of 58 patients from 17 primary care trusts who have participated in the scheme since its inception. Many of those who were offered personal health budgets responded positively to the offer of greater choice and more control, but the prospect of budget-holding caused confusion and anxiety for others. Lack of information before and during the care planning process exacerbated the problem. Two-thirds of participants were not told how much money they had been allocated before they were asked how they would like to spend it. Many were not given a choice of how their budget would be managed and in some cases were not given illustrative examples of permissible expenditures. A few patients were disappointed when their requests were turned down by the primary care trusts' assessment panels, or when the care planning process led to long delays in the delivery of agreed services.
In some cases personal budgets were used to enable people to live more independently, for example, by employing carers, purchasing mobility aids, or providing travel to support groups or day centres. Others used their budgets to pay for treatments such as physiotherapy, speech therapy, podiatry or exercise classes. These uses of NHS funds are probably uncontroversial, but the fact that the budgets were also used to pay for services, such as reflexology, reiki, aromatherapy, electronic personal organisers and music lessons, will no doubt lead to some raised eyebrows.
The scheme is still in an early stage of development and the costs are currently manageable, but when the government's ambitious plans are fully realised, personal budgets may start to shift resources into complementary therapies or non-health care items, potentially making some of NHS services non-viable. People – especially the clinical commissioning groups who will have to underwrite the personal health budgets – will quickly lose enthusiasm for them if the clinical benefits are not abundantly clear, or if they enable choices only for those patients who have the confidence and capacity to take on individual budgets at the expense of those who do not.
Meanwhile, the Year of Care Programme has been working quietly without ministerial fanfare to demonstrate that personalisation of care for people with long-term conditions is possible without the use of personal budgets. This programme – which has won the enthusiastic support of the Royal College of General Practitioners – has been developing and testing approaches to collaborative care planning and micro-commissioning, using diabetes as an exemplar. The programme enhances annual health checks by incorporating shared decision-making and self-management support, and ensures that patients are offered a choice of local NHS and community services through responsive commissioning. Those involved in the programme are clear about the benefits: a better experience for patients and real changes in self-care behaviour; improved knowledge and skills for professionals; greater job satisfaction, better organisation and team work, and improved productivity.
What the Year of Care Programme has demonstrated – and those promoting personal budgets may still need to learn – is that changing the dynamic between patients and health systems to produce responsive, personalised care involves significant cultural change and application of the principles of shared decision-making. These include a defined menu of effective options, evidence-based information on risks, benefits and uncertainties, and supportive decision coaching to help patients make personally-relevant choices. Simply disaggregating budgets and allocating them to individuals is never going to be enough.
Read Angela's publication: Making shared decision-making a reality