‘Personalisation’ has been around as a buzzword for a long time. But the consensus over whether this means ‘personal budgets’ is breaking down in health and social care
Close to 10 years ago, the term ‘personalisation’ was coined in a Demos pamphlet about public services reform. The concept quickly became synonymous with ‘personal budgets’, the funding allocation that gives control to individuals. Personal budgets were first applied in adult social care and have since spread to children’s services, wider disability services and, most recently, the NHS.
Now the cross-party consensus that has driven their implementation has begun to fracture. On left and right, sceptics are suggesting that we can personalise public services without personal budgets. This is a dangerous illusion. Without personal budgets to give real power to individuals, their priorities and preferences are all too often ignored.
In a recent speech to the Society of Local Authority Chief Executives, shadow health secretary Andy Burnham said that while personalisation was the future in health and social care, that did not necessarily mean personal budgets, as they would fragment the system. His parliamentary private secretary, Debbie Abrahams, has also expressed support for personalised healthcare, while rejecting personal health budgets.
The Conservative chairman of the health select committee, Stephen Dorrell, has joined these two Labour figures. He argued at a recent Policy Exchange discussion that people’s views should drive change in the NHS but rejected personal health budgets, saying they did not offer extra choice or value.
These comments seem to be rooted in a conviction that bureaucracies can know and respond to individual priorities and are supple enough to adapt to individual feedback. The evidence is strongly to the contrary. Care agencies commissioned by both the NHS and social care are unable to make their schedules flexible enough to get each person up and dressed at the time they require, forcing many people to drop out of employment.
For example:
● With his personal health budget, Tom can hire and timetable his own team to ensure that he keeps his job in Manchester United’s disability liaison office, even with significant health problems.
● Every NHS trust continues to offer psychological therapies in blocks of 12 weeks, no more, no less, and there is no option to choose your therapist, although evidence from the National Institute for Health and Care Excellence highlights the importance of that relationship. With a personal health budget, Yve was able to go back to a therapist she had worked with before and negotiate a discount to have more sessions for the same price.
● When Malcolm was diagnosed with frontal lobe dementia, NHS commissioners would only allow him to return home if he attended the day service they commissioned each day. There, he became more aggressive, needing four people to manage him and increased medication. Rent on a flat near his home, a Sky Plus box and his own care team have kept him happier, safer and significantly cut his medication.
Of course, there are many aspects of NHS care where a personal health budget would not be suitable and where other types of choice and means of soliciting the views of individuals are more appropriate. Elective surgery, emergency and inpatient care and GP services are all areas where personal health budgets have been ruled out. But the majority of NHS spending now goes on the care of people with long-term conditions. For large numbers of these people, the level of care and support received from the NHS affects not just their health but their ability to live well.
A personal health budget allows a publicly funded health care system to respond to very specific needs by devolving power to people to shape and integrate their care in line with their priorities and those of their family.
The national personal health budget evaluation, a study of pilot schemes commissioned by the Department of Health, shows that giving individuals choice and control not only improves their quality of life and wellbeing, but also reduces their use of hospital care by £1,300 per person per year. But the evaluation is clear that how personal health budgets are implemented matters enormously.
Poor implementation in adult social care underpins some of the wider dissatisfaction with personalisation that has seen some of its original proponents back away. Stretching targets for the take-up of personal budgets under the previous government led to a rush to offer budgets, a significant number of which did not give individuals any greater choice. People had budgets in name only. Add to this a 40% reduction in local authority spending since 2010 and personalisation has become tainted by cuts and tightening of eligibility.
No similar targets have been set in the NHS, which creates its own challenge. Expecting an NHS dominated by a medical culture and powerful provider organisations to devolve power to individuals through encouragement alone is unlikely to result in change. The care services minister, Norman Lamb, recently sought to force the NHS’s hand by strengthening the right to ask for a personal budget in continuing health care. But something more will be needed. A requirement for each clinical commissioning group to spend even a small proportion of its budget for long-term conditions through personal health budgets would be enough to kickstart a change without falling into the trap of counting budgets.
The NHS is rightly revered but remains institutional in nature, whilst today’s challenges require an individualised response. Personal health budgets make it personal.
Vidhya Alakeson is deputy chief executive at the Resolution Foundation
This opinion piece was first published in the December edition of Public Finance magazine
