Health Service Focus

Personal health budgets

By April 2014, up to 56,000 people getting continuing NHS-funded healthcare will be able to request a personal health budget, following a series of successful pilots, the evidence from which suggests that those with the highest health needs get the most benefit. Although the Department of Health strongly backs the idea, some have concerns, including the Royal College of Nursing. NHE spoke to RCN assistant policy adviser Laura Clarke to find out more.

Results from a three-year pilot of personal health budgets across the country, including at 20 in-depth sites, were published at the end of 2012 with the evidence showing that allowing people with a long-term condition to design their own package of care can improve their quality of life and decrease the amount of times they had to attend hospital.

The Department of Health is now keen to expand their use, since they “promote a more effective and equal relationship between NHS professionals and people who use the NHS”, it says, and can also save money. An Audit Commission report last year noted that PHBs allow people “to become participants, rather than recipients” which makes care more accessible and responsive. “By getting it right, there is less need for crisis management and more likelihood of improved outcomes, which can deliver real system level savings for the NHS.”

Others are wary on any focus on PHBs as a way to save NHS costs. Laura Clarke of the Royal College of Nursing told us: “We think, particularly in light of the current fi nancial context, that there’s a real danger in seeing this as a money-saving policy, because it isn’t. You need lots of support, particularly clinical support, to have an effective personal health budget and ensure your care plans are adequate along your patient journey.

“It doesn’t seem reasonable to expect that money’s going to be there to ensure the policy can be implemented as it should be.

“We would want to see the ‘traditional’ existing services carry on running. That costs more money, because then you’re offering two different types of service. You’re not getting the same economies of scale, if other people take their procurement or purchasing elsewhere.”

Despite the hopes that costs could come down at the system level, Department of Health guidance is careful to avoid suggesting that PHBs could cut the costs associated with individuals’ care, noting: “It is also important to avoid personal health budgets being seen as a cost-saving exercise. Personal health budgets are likely to be cost neutral and a way to get better value from the money that the NHS already spends.”

‘Top-ups’ and inequality

Clarke said: “We also think that there’s a danger – and this was seen in some of the evaluation of PHBs – that people might start to ‘top up’ their own PHB.

“In the evaluation, it was often because people weren’t clear about what was included, because there’s some blurring around the edges about what they could buy with their money. The NHS is free at the point of delivery: we don’t want changes to that.

“We also think there may be exacerbations of inequalities, where some people who are more able to manage PHBs and who get the support they need would be able to access them, whilst others, particularly older people as we’ve seen with personal [care] budgets, aren’t able to cope with them or don’t want them. There could be a postcode lottery.”

Clarke also questioned the reliability of the results of the pilot study evaluations, saying: “It only really ran for a year, because it took ages for people to be recruited. The evaluation wasn’t necessarily as in-depth as you might have expected it to be.

“All they could say is that it’s not really had an impact on worsening outcomes. They were really pleased about, because they were really fearing it might get worse.

“Some groups found that the patient experience had improved. None seemed to be particularly harmed by it: but that’s not a ringing endorsement of the policy.

“That’s not to say we’re against it: but they need to take time to assess this and make sure it’s used appropriately. The biggest thing, we’ve always said, is that they have to be optional and used for people they’re appropriate for.”

But Clarke acknowledged that when used well, there was scope for PHBs to be “really positive”. She suggested that young disabled people, and younger people generally, seemed to benefit particularly.

Many users have especially welcomed the fl exibility when getting personal assistance, not having an agency dictating what times they visit. “That seems to be one of the best things that PHBs seem to allow, which the NHS can’t quite deal with sadly,” she told us.

Challenging existing systems

Department of Health guidance acknowledges that PHBs challenge existing ways of working and established systems, and so will encounter resistance.

It notes: “Experience in pilot sites has shown that the NHS can be extremely risk-averse, with a tendency to maintain existing service patterns and ways of working…It is important to avoid these concerns being used as reasons to impose restrictions that limit choice and control – for example by not telling people the value of their budget, or restricting the use of the budget to services that are already commissioned.

“There is little point in offering personal health budgets unless people can use their budget in new ways that are right for them.”

It notes that part of the point of PHBs is to ensure a person’s ‘whole life’ needs are considered – not just their specifi c health needs. They are supposed, via a detailed care plan developed in consultation with health professionals, to promote a holistic approach to health and well-being.

Care minister Norman Lamb (pictured above) said: “Independent analysis has now shown that personal health budgets can put people back in control of their care and make a signifi cant difference to their quality of life. It’s inspiring to hear the human stories of success that these budgets have brought to people.

“The evaluation shows that those with the greatest needs benefi t most from personal health budgets. That’s why we are giving people on NHS Continuing Healthcare the chance to get one first. And, I hope more people who could benefit will be given the option of one.”

There are not precise targets on getting people to take up PHBs, and the Department of Health has avoided suggested its ultimate goal is 100% take-up, as there was previously for personal budgets for social care.

Clarke suggested that there were some discrepancies there, because sometimes the DH seems to suggest PHBs are for people for whom traditional services don’t work, and sometimes it suggests they could be good for virtually everyone managing a long-term condition, rather than just a last resort.

She said: “Because of that, obviously it’s not quite ringing true…there’s a bit of tension in what they’re saying.”

The effect on nurses

NHE also asked Clarke how the introduction of PHBs will affect care providers, NHS staff and the RCN’s own members.

She explained: “There are issues around safeguarding: the RCN would defi nitely like to see the regulation of healthcare assistants as part of the safeguarding solution, but whilst the care plan is key to that, it needs regular review and clinical input.

“But there really is a danger that these people are exploited by others who might be employed, intentionally or unintentionally.

“There are also issues around training and support: there will be cultural changes. It will take time. There will be a relationship that might change when nurses start delegating to different assistants.

“They will be responsible for the people they’ve taught to do certain things, who might be being paid. There is an issue around safeguarding and a nurse’s code of conduct, ensuring those people are fi t to do the job, hence why we want regulation of healthcare assistants.”

She concluded: “Lots of trusts are still fi nding their way on exactly how this will work and how they decide what’s in and what’s out of a plan, and ensuring they’ve got the right mechanisms to form a panel if they need to when deciding on a difficult case.

“It’s still quite early days.”

The Department of Health is allowing a lot of flexibility in how PHBs are implemented in local areas. Examples given include using costed care packages; banding scales based on NHS care pathways; costing previous use of NHS services; joint health and social care budgets; fl at rate, one-off budgets; payment by results; and outcome-based budgets.

It says: “It is not necessary to develop a sophisticated budget setting tool before beginning to offer budgets; it is better to start on a small scale and learn from experience.

“Whichever approach is taken, it is important to keep the purpose of personal health budgets in mind, keep the focus on outcomes and keep the system simple and fl exible for people with personal health budgets and front-line staff.”  

Managing PHBs

Personal health budgets can be managed in three ways, or a combination of them:

• Notional budget: the money is held by the NHS
• Third party budget: the money is paid to an organisation that holds the money on the person’s behalf
• Direct payment for health care: the money is paid to the person or their representative

The NHS already has the necessary powers to offer personal health budgets, although only approved pilot sites can currently make direct payments for health care.

The costs of emergency/unplanned care, medication, prescriptions and other chargeable services, and most primary care services such as GP visits should not be included in a personal health budget.

(Source: ‘How to set budgets – early learning from the personal health budget pilot’, Department of Health)

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