Delivering Personal Health Budgets

A Guide to Policy and Practice

Alakeson, Vidhya

• Publisher: Policy Press
• Year: 2014
• ISBN:
  9781447312161
• Edition: 1
• Topic: Médecine
• Subtopic: Politique de santé

Personal health budgets are an important new tool to improve the lives of people living with long-term conditions and disabilities by giving them greater choice and control over their healthcare.This is the first step-by-step guide to their implementation. Using current evidence and best practice identified by pilot sites, Delivering personal health budgets contains everything there is to know about the purpose and history of personal health budgets, the evidence for their effectiveness and the challenges they pose to traditional healthcare systems. It describes the essential infrastructure needed for personal health budgets and includes implementation checklists.The book focuses on how personal health budgets can be implemented to achieve the best possible outcomes for individuals, while real life stories from personal health budget holders bring their potential vividly to life. Delivering personal health budgets is essential reading for commissioners, healthcare providers, clinicians and policy makers who are looking for an informative and authoritative guide.

Section 1

Introducing personal health budgets

ONE

Personalisation across public services

The purpose of this book is to set out the objectives underpinning the roll-out of personal health budgets in the National Health Service (NHS); to provide an overview of how PHBs can be implemented to best deliver on those objectives; and to identify some of the barriers to implementation and how they can be overcome. Within the NHS, PHBs are highly innovative and present new challenges to commissioners, clinicians and individuals. But just as they have a shared history with personal budgets in social care (discussed in Chapter 3), they are also part of a set of new initiatives that are driving personalisation across public services. At the heart of each initiative is a common set of principles, a similar design and a common delivery mechanism – an individual budget and a personalised plan for how the individual budget can best be deployed to help people achieve their goals. This chapter puts PHBs in the NHS into their wider context and looks at the spread of personalisation across public services.

The principles underpinning personalisation across public services

• A new relationship between the citizen and the state based on co-production.
• Self-determination expressed through informed choice, control and accountability for the individual – do less to people and more with them.
• Government should step back, making space for individuals to lead their lives as they choose.
• A more preventative approach with support provided in a timely way.
• The ability for individuals to use resources in new ways.
• Making full use of the expertise of the voluntary and private sectors, disabled people’s organisations and peer support.
• Affordable and sustainable support, with transition costs grounded in austerity measures.
• Local freedom and accountability, with Whitehall as adviser.

Source: Adapted from an Office for Disability Issues workshop facilitated by the author, August 2011

From personalisation to open public services

As discussed later in Chapter 3, the concept of personalisation arose out of a complex interaction between the disabled people’s movement for independent living and the work of think tanks and policymakers. By 2007, it had become a central idea within public service reform under the then Labour government and the governing idea in adult social care. Personalisation provided a softer alternative to market-based reforms in health and education that sought to extend choice through competition. The basic concept that services should be tailored to the needs of those who use them is one with which it is hard to disagree.

In fact, the ongoing popularity of the concept of personalisation owes much to its capaciousness. It is loose enough to receive support from across the political spectrum, with each party lending it its own particular emphasis (Needham, 2011). For Labour, it is a route to greater individual empowerment and a way to shift the relationship between the individual and the state from one in which the state does things for people to one in which it does things with people (Mulgan, 2012). For Liberals, it is an approach to public services that puts power in the hands of people to decide which goals to pursue to improve their lives (Reeves, 2010). When announcing the roll-out of PHBs in November 2012, Liberal Democrat Health Minister, Norman Lamb MP, described them as a ‘liberal’ approach to NHS reform. For those on the right, personalisation can be seen to emphasise personal responsibility and market-based solutions that exploit consumer power rather than state-led action. As such, personalisation is a term well suited to Coalition politics as it provides room for different definitions to coexist.

The current Coalition government built on the foundations laid by Labour through the publication of its Open public services White Paper in July 2011 (HM Government, 2011). At the heart of its framework for public services set out in the White Paper are choice and decentralisation: the government should increase choice wherever possible, and services should be devolved to the lowest possible level. In the case of policing, this may be devolution from national to local government and for leisure services, from local government to communities themselves. In the case of services such as health, education and housing support that are used on an individual basis, the White Paper commits to put power in the hands of people. This transfer of power, the White Paper argues, is the way to create the best public services for the money spent:

Our preference is that power over the public services that people use as individuals should go to those individuals wherever possible. No one knows an individual’s preferences better than they do, and while some people may need extra help to choose the services they want, at the centre of our vision is the belief that people should be trusted to choose the best services for themselves rather than being forced to accept choices determined by others. (HM Government, 2011, p 14)

The White Paper distinguishes between areas where there is some public benefit in the government setting limits on how public money is used by individuals and areas where individuals are best placed to choose how best to meet their needs. For the former, vouchers and per capita funding such as the Pupil Premium in education are the most appropriate mechanisms. For the latter, the White Paper identifies a huge opportunity to shift power to individuals through individual budgets, delivered as cash payments where possible. The initiatives across government outside the Department of Health that are seeking to accelerate the transfer of power to individuals through individual budgets are described here.

Right to Control Trailblazers, Department for Work and Pensions

As well as receiving support from adult social care, many disabled people access a range of other services that are the responsibility of other government departments, such as support for employment through the Department for Work and Pension’s Access to Work scheme. The Right to Control Trailblazers are seeking to maximise choice and control for individuals with disabilities by providing them with a single integrated individual budget across six funding streams from three different Whitehall departments: Access to Work, Work Choice, Disabled Facilities Grant, Independent Living Fund, Adult Social Care and Supporting People. The centrepiece of this attempt at integration is a legal right for individuals to request that their services and supports be delivered in an integrated way and through an individual budget if they choose – the individual right to control.

There are seven Right to Control Trailblazer local authorities or local authority partnerships that started implementation in 2010 and were intended to finish by the end of 2012. Given limited progress by the end of 2011, the Trailblazers were extended until December 2013 in order to give areas more time for implementation. An early process evaluation found that most disabled individuals were unaware of their ‘right to control’, and staff also lacked awareness and understanding of the approach. However, staff were more positive that the Right to Control was encouraging partnership working across services, even if there was some way to go to make the approach mainstream. Pulling together different funding streams into a single budget is a major challenge, particularly in an environment of significant cuts to public spending. The Trailblazers face an ongoing tension between making the individual right meaningful, while ensuring sustainability and fair access for all (Tu et al, 2012).

Special educational needs and disability pathfinders, Department for Education

Running alongside the PHB pilot which focused on adults with long-term health needs has been a parallel initiative for children which was launched in the 2011 Green Paper, Support and aspiration: A new approach to special educational needs and disability (DfE, 2011). From April 2014, parents of children with special educational needs and disabilities (SEND) will have the right for their child to have a single assessment across education, health and social services, a single plan from zero to 25 years of age and to control parts of that plan through an individual budget.

This approach is being tested over an 18-month period in 20 pathfinder sites consisting of 31 local authorities and their health partners in order to inform wider national roll-out. The SEND pathfinders build on an earlier pilot of budget-holding lead professionals for disabled children (HM Treasury and DfES, 2005) and several high profile examples of the use of individual budgets for young people in transition to adult services (see Epilogue). An interim evaluation at the half-way point concluded that the pathfinders had not made the speed of progress anticipated, with individual budgets being one of the least developed aspects (Craston et al, 2012). As this and the evaluation of the Right to Control initiative highlight, implementation of individual budget programmes is always challenging. They require new infrastructure, new ways of working and a complete culture change, all of which take time to develop and implement.

Rough sleepers, Department for Communities and Local Government

One of the smaller individual budget initiatives was the pilot undertaken by the homelessness charity, Broadway, for long-term rough sleepers as part of the City of London Corporation and Department for Communities and Local Government’s strategy to end rough sleeping. Each of the 21 rough sleepers had a budget of up to £3,000 and was allocated a broker with whom to develop a plan to move off the streets.

Of the 21 participants, 16 moved into accommodation and a further three were awaiting accommodation offers at the end of the evaluation. This is an impressive record of success given that some of the participants had been on the streets for up to 45 years. Participants spent less than they were allocated, £794 on average. As with all other individual budget programmes, the personalised plan was found to be as significant in the pilot’s success as the budget itself. As the evaluation concludes, ‘the personalised approach has brought people elements of choice and control not provided by standard offers of support, alongside intensive support from one trusted worker’ (Hough and Rice, 2010, p 1). The pilot ended in 2011, but individual budgets have been incorporated into Broadway’s standard way of working with rough sleepers in the City of London.

Personalisation and public service integration

One of the ongoing challenges for public services is how to integrate to meet the needs of those who rely on more than one service. For example, one in eight budget holders and a majority of carers in the PHB evaluation also received social care funding (Forder et al, 2012). All too often, users of multiple services find themselves retelling their story at each assessment and review. They have to disentangle their lives to fit the bureaucratic boundaries of services, and either find that support from different services duplicates or they fall through the gaps between services. At the same time, they present a significant cost to government that is only increased by a disjointed service response.

Clearly, there is a risk that, as personalisation expands across public services, individuals end up w...