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Thousands of patients across England will from 1 April be expected to individually manage the funds allocated for their healthcare, which have been merged into their social care ‘entitlements’, the NHS announced this week..
In Barnsley, Cheshire, Tower Hamlets, Hampshire, Portsmouth, Stockton and the South West of England, 10,000 patients with complex needs will be a single ‘pot’ of money from which they will be expected to purchase both their health and their social care needs.
The details vary by area but the main groups affected are older people with multiple health needs, children with disabilities, and people with diabetes, dementia, learning disabilities, or serious mental health problems.
The move was hailed by new Chief Executive of the NHS Simon Stevens as a ‘radical initiative’ which would ‘make a reality of person-level health and social care integration’.
But the announcement comes as new research reveals widespread fears amongst health professionals, that ‘Personal Health Budgets’ (PHBs) represent the privatisation of the National Health Service - and considerable doubt amongst patient groups that they will be effective, safe or appropriate.
In an article published in International Journal of Health Services, Public health expert Professor Alex Scott-Samuel exposes the different views about PHBs amongst healthcare experts, healthcare providers, patients and support groups.
Baroness Barbara Young, the Chief Executive of Diabetes UK, raises concern over the effectiveness of Personal Health Budgets to diabetes patients: “Diabetes is a complex condition. The development of its complications can be unpredictable and lead to multiple co-morbidities. Research in this area has identified that personal budgets are likely to work best when conditions are stable and predictable.
“Therefore Diabetes UK takes the position that personal health budgets are not suited for clinical diabetes care delivery and may impact negatively on quality of care and lead to fragmentation of service.”
A recent pilot in 70 primary care trusts covering patients with a range of long-term conditions was last year deemed a success in the official evaluation, which found that PHBs improved care-related quality of life and psychological well-being. The pilot programme found that typically, PHBs had been used to pay for services such as physical exercise, alternative therapies, or to pay carers, and were welcomed by some patient groups. However the official evaluation found PHBs did not improve clinical outcomes.
Other studies of personal budgets by social care experts - who in principle support the idea of greater autonomy for service users - have found that in practice, only those who had the strongest abilities, support networks, and/or highest budgets - perhaps around 10% of all users - really benefitted, and that this often depended on ‘sweeteners’ of extra cash.
But NHS England is undaunted, and estimate as many as 5 million people could be paying for their healthcare via personal health budgets by 2018.
NHS boss Stevens is a powerful figure in all of this. Since the 2012 Act dramatically reduced ministerial accountability for the NHS, the NHS CEO’s role has been super-charged, with politicians largely taking a back seat on new NHS announcements. Stevens - who advised Tony Blair on his pro-market NHS 'reforms' - has spent the last few years as Vice President of the European Division of US healthcare megalith, United Health before he was hired to take the NHS reins in 2014.
This week Stevens was ubiquitous on the airwaves, promoting his version of ‘integrated’ health and social care through a shift to ‘new provider models’ and to move care ‘away from hospital and closer to people’s homes’. Again, there are fears amongst experienced health campaigners that what is actually envisaged, beneath the jargon few journalists have seriously penetrated, is a loss of NHS hospitals and a shift towards greater private provision.
Even less noticed by the media, however, is Stevens’ enthusiastic push towards Personal Health Budgets, which are able to be spent on both NHS and non-NHS providers. He used his first speech as head of the NHS last year to announce that Personal Health Budgets would be available to anyone with a long term condition who requested one from April 2015.
But the 10,000 patients getting ‘Integrated’ health and social care personal budgets this April have not requested this arrangement - and they are just first wave of this scheme.
Professor Scott-Samuels’ research highlighted widespread concern amongst health professionals about the ability and/or desire of patients with chronic diseases to manage their own healthcare budget and to negotiate with care providers, assuming that the patient was aware of all of the services available to them, and their relevance. Budgets were also used to pay for services no longer provided by the NHS, for example acupuncture, and in one case to buy a football season ticket, he found.
However, the key area of concern is that Personal Health Budgets are part of the transition to an insurance-based system, and the end of an NHS that is available to all, regardless of wealth.
Already in social care, where personal budgets are long established, people are forced to ‘top up’ their state-funded budget from their own money, and provision is also dependent on a means-test.
The government has in the past denied that NHS patients will be able to - or have to - make similar top up payments for their medical care. But if personal budgets and the current model of health and social care ‘integration’ continue to be rolled out apace, particularly in a context of ongoing ‘austerity’, it is difficult to see how this can be avoided.
Professor Scott-Samuel said: “Personal Health Budgets are being introduced at a time when rapid privatisation of the English NHS is taking place and where restrictions are being placed on people’s access to healthcare.
“As a result many see their introduction as a diversionary gimmick designed to help pave the way for the conversion of the NHS into the insurance-based system which may believe is the intention of the UK government.”
Author's note: since publishing this piece I have been contacted by the head of 'Integrated Personal Commissioning' at NHS England, saying that the pilot scheme is 'optional'. However I remain doubtful, on the basis of the information thus provided, how the scheme is truly voluntary. I have asked him what happens exactly if patients in the pilot areas don't want to take part and in particular what happens if they do not want their health and social care budgets to be merged. I await answers.
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