The Perceived Threat and Real Opportunity of Personal Health Budgets

NHS Shared Business ServicesOpinion Article by Benjamyn Damazer, head of commissioning at NHS Shared Business Services.
Personal Health Budgets (PHBs) and personalised care are some of the most central components of the Five Year Forward View. People are to have more direct say in how money is spent on their individual care and wellbeing. Their prominence is growing fast. Clinical commissioning groups (CCGs) are now required to show how they plan to expand their current PHB activity to reach 100,000 people across England by 2020.

Not everyone shares NHS England's belief that PHBs can lower costs and improve outcomes. These concerns are amplified by media stories that focus on the few instances where patients have spent money on items such as holidays and summer houses.

But PHBs can be truly transformational and help realise the vision for a people-powered health service. They need support over the coming months and years.

What do PHBs offer?
PHBs enable patients to work with care professionals to identify and manage their own care, drawing on an individual budget for care services. Still in the early stages of development, NHS England would like to see many thousands more use PHBs.

Such usage would see frontline healthcare staff having to coach patients and help them make choices that deliver the best agreed outcomes, co-designing care in the most effective way.

This should help empower some patients to manage and shape their own health. Improving self-care can help deliver a sustainable NHS, so that people are more engaged in their own care, and able to make informed decisions without the need to take up valuable healthcare resources.

This can help achieve increased patient activation, which, as GP Ollie Hart says, "will eventually liberate us from wasting time doing the wrong things, in the wrong way, and help healthcare professionals to shape our systems around what patients need at each stage of their life".

Opposition to PHBs
Despite the promise of PHBs, they are not universally welcomed by all.

Some doctors question the evidence base for PHBs. Quite rightly, any change in delivering healthcare should be able to demonstrate clinical benefits. And for PHBs, this can be contentious.

Research into early pilots of PHBs showed that patient wellbeing and quality of life appear much improved; clinical indicators are not conclusive.

But, as one policy paper from The King's Fund on PHBs indicated, who should determine what is valid evidence? What is the most valid outcome for a patient?

Critics also point to the use of the money on holidays and other ‘spurious’ items, equating the use of PHBs as the healthcare equivalent of the MP expenses scandal. However PHBs can only be spent on products and services agreed with care professionals, and can help improve someone's life.

There may be fears over how commissioners can implement these efficiently and at scale. NHS finance systems, for example, are not built for patients. But such implementation issues can be addressed and overcome, and technology can help make the use of PHBs straightforward for patient, supplier and commissioner alike.

Others may say that some patients would not be able to manage such budgets themselves; again, this can be addressed, through the legitimate authorisation of trusted individuals, for example.

But most significantly, in an NHS where 'culture eats strategy for breakfast', some care givers may fear that PHBs could replace their role as supporting individuals in their care. It is this that can be the most challenging aspect of PHBs.

NHS staff at all levels can sometimes see patients as passive recipients of care. Even patients themselves can feel and act the same. This is a dangerous sentiment.

With a growing elderly population and increasing levels of need, care providers need to empower patients to be active participants in their own health - or risk being overwhelmed by demand. The culture of 'doctor knows best' could become a zero-game collusion between well-meaning health professionals and the public at large.

What PHBs can deliver
As policy makers across the world are stressing, people need to take control over their own health to help cope with burgeoning demand on health and care providers. PHBs are an important part of that process. They enable shared decision making between care provider and patient, and encourage the prospects for co-designed care.

Not only can this deliver care that can cost the same or less, it can have immense benefits for the individual and the family that supports them. Pilots of PHBs also show that giving patients control of spending decisions for their own care benefits them and saves the NHS money.

Stories on the PeopleHub website show the difference that PHBs can make. Patients no longer have to wait for district nurses to have dressings changed; a personal assistant can be trained to do the same.

People's lives are improved immeasurably by taking a more active hand in the care they receive. The impact on outcomes for the individual can be immense.

Embracing PHBs is a challenge for care providers. As James Jeynes recently said, when calling for the use of PHBs for his son, Lewis, 12, who was diagnosed with terminal Batten Disease, "delivery of truly personal, personal health budgets will only work if the agencies ease up a bit and genuinely collaborate and co-design with those who know the recipient best". Agencies need to 'let go' and empower people to decide on their own care.

The Five Year Forward View echoes his sentiments: "Personalised care will only happen when statutory services recognise that patients' own life goals are what count; that services need to support families, carers and communities; that promoting wellbeing and independence need to be the key outcomes of care; and that patients, their families and carers are often 'experts by experience'."

CCGs are expected to lead this vision, and help increase the number of PHB holders to between 50,000 and 100,000 by 2020/21.

This only represents around one or two people per 1,000 population, and addressing the needs of such relatively small numbers may appear overly complicated. But technology can make the process of implementing PHBs much more straightforward, giving CCGs visibility over how money is being spent. Most importantly, PHBs can make a massive difference to patients' lives.

There will always be questions over the design of any care provision; but PHBs give the NHS an opportunity to help balance the books and put patients first.

CCGs and PHBs are central to a future, people-powered NHS. Let's make this happen.

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