Image: Monopoly Money. David Muir/Flickr. Some rights reserved.
Personal health budgets are to be rolled out to many more patients and combined with social care personal budgets, Simon Stevens, NHS England’s new Chief Executive announced yesterday.
The announcement has been framed as handing money over to patients and giving them more direct control over their lives. Unsurprisingly, this has so far largely been welcomed. Stevens talks of ‘north of five million patients’ having a combined personal health and social care budget by 2018.
But as spending on both social care and the NHS contracts, what is the evidence underpinning this massive shift in resources?
It is helpful to look at what has happened in social care, where personal budgets have been operating for some years. There, advocates promised that they would make support better and cheaper and reduce bureaucracy.
Instead, new layers of bureaucracy were created by the so-called ‘resource allocation system’ (RAS), according to the independent evidence to date. The RAS was intended to let people know the size of their budget upfront to make sensible decisions about how to spend it – but has conspicuously failed to do that.
Unfortunately, it looks as though this is the same model that it is planned to run-out in personal health budgets.
Trying to roll out social care personal budgets to millions of people, as the government has itself admitted, has often meant nothing more than many people receiving the same service – frequently getting less.
As Coalition funding cuts hit home, they are rebranded as a ‘managed personal budget’.
This has brought the policy into disrepute among many practitioners and service users. Where service users do seem to have benefitted greatly is where they have actually directly received a cash or ‘direct payment’. However, these lucky people have tended to get more than others, which may be the underpinning reason for the improvements they have experienced. And this sweetener is now diminishing as cuts bite.
Consumerism has its limits when applied to long term care and health services. The consumer may be king or queen when it comes to buying a phone or choosing a holiday, but it can be a different issue when it’s a matter of dealing with a personal health crisis, the onset of impairment or mental health problem, the complexities of human services and running our own support system.
We know from the pioneering work of the disabled people’s movement that most of us are likely to need help for this to work; an advocate, an adviser, a guide – an on-tap personal shopper/tour guide.
This means so-called self-funding social care service users often opt for residential care over alternatives offering greater independence and support at home.
If the new combined ‘personal patient budgets’ are to work, they need to invest heavily in supporting these new ‘consumers’. They need to offer help to enable access potentially empowering arrangements.
Otherwise the evidence suggests that it is only likely to be the most confident, assertive and experienced patients/service users who will really benefit. Those without such determination or committed family members to help them, may find themselves lost in a market that is still under-developed and increasingly being shaped by large corporate for profit interests
And that leads us to the real conundrum posed by personal health budgets. They have made some sense in social care - a means and needs tested service. But the NHS is meant still essentially to be a universal service, free at the point of delivery, paid for out of general taxation.
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So what happens if we are allocated a personal budget and then need more? Are we to be cast adrift? What happens to our entitlements from a universalist service, when we’ve spent out?
The advocates of Personal Health Budgets argue the NHS is inflexible, top-down and over-bureaucratic. So isn’t it time to address these problems, rather than thinking they can be sidestepped by an initiative that already has been shown to have its own big problems?
And what happens to the combined personal patient budget if we are deemed eligible for a personal health budget but not a social care one? As we already know from social care, with personal budgets, the devil is definitely in the detail, but policymakers seem determined to think big and move fast. Calls like Ben Goldacre’s for better evidence have so far been ignored.
The well organized and vociferous advocates of personal health budgets duck such questions. The talk is all of choice, control and liberation.
The arguments are presented through a few positive first-hand stories. But there’s a big difference between small scale programmes with boosted funding, and a large scale day to day policy.
We have a government committed to reducing public expenditure, a new NHS Chief Executive from the private sector and more and more commissioning of NHS services from the private sector. We should heed rising concerns that Personal Health Budgets may actually be part of the much bigger neoliberal project that is currently being advanced for our health service, hollowing it out from within.
A ‘partnership’ between global corporations and people described as ‘the most vulnerable patients’ seems unlikely to be an equal or positive one. We should be asking what place an initiative that is in essence a rebranded voucher system, has in the NHS - most publicly loved inheritance from the post-war welfare state.