Personal budgets have serious implications for the ethos of the NHS which must be considered if health and social care are to be merged - universality and provision based on need are principles we should not be so quick to abandon.
As the government considers shifting more NHS funding to a ‘personal budget’ system, it should look to the experience of social care, where the evidence base for this massive and costly policy reform appears increasingly uncertain, and the initiative appears to have stalled.
In 2008, the rolling out of personal budgets was hailed by government as the route to ‘transforming’ social care and achieving greater ‘choice and control’ for service users.
Personal budgets were sold to politicians as a method of getting better services for less money. Not surprisingly this unlikely promise has not been realised.
Social care, as we have seen, is a service to which people have few if any statutory entitlements. It is easy to see how a consumerist approach to personal budgets can reinforce this, serving essentially as a voucher system for the ever-reducing numbers who qualify for social care support. The introduction of personal budgets in the NHS raises serious ideological and philosophical issues. How could this ever be consistent with the underpinning philosophy of the NHS - which commands enormous support and loyalty from the population - with its principles of a universal entitlement and a service free at the point of delivery? It is difficult to see.
The allocation of a fixed sum to someone with long term needs in the NHS (a budget which may then be reduced and restricted over time to judge from the social care experience), hardly sits comfortably with their notional entitlement to whatever help they might need, both over time and in line with the changing nature of their condition – healthcare according to needs, not means. No wonder that so many disabled people increasingly see ‘personal budgets’ as a route to rationing, reduced entitlement and the abrogation of collective services on the quiet. More convincing arguments to refute these fears are now needed from personal budgets’ proponents than they have so far shown themselves able to offer.
Personal budgets in social care have frequently been equated with ‘personalisation’. The government has itself been guilty of this. Personalisation means a lot more than changing the delivery mechanism for social care, which is all personal budgets amount to. The largest independent study of personalisation highlights that for service users and carers it must entail much more fundamental change in the social care system. These changes seriously challenge its existing ‘one size fits all’ and institutionalizing approaches and respond instead in a person-centred way to meet the unique needs and common rights of service users. This demands many more changes than simply offering people the same menu of services and merely putting a price on them, the reality of many so-called ‘managed’ personal budgets. It demands a more skilled, better supported workforce, a higher quality range of providers, reduced reliance on unpaid carers, more flexible, less bureaucratic organisations and person-centred practice. Most of all it needs sufficient funding and a changed culture based on enabling people to live to the best of their ability instead of framing them in terms of their deficits.
Key elements of the dominant model used in social care have failed. The idea of ‘up-front allocation’ so that service users would immediately know their entitlement appears unworkable in practice. The ‘resource allocation system’ that was meant to cut bureaucracy has actually added to it.
What does seem to help is where social care service users receive ‘direct payments’ to purchase their own package of support. But the number of direct payments has stagnated. More to the point this was a much earlier idea, developed by the disabled people’s movement in the 1980s to support their independence which never received sufficient state encouragement and support. Moreover it was tied to a coherent philosophy, the philosophy of ‘independent living’. This was pioneered by disabled people and emphasized that the direct payment was required to provide the support that disabled people needed to live their lives on as equal a footing as non-disabled people. It also called for an infrastructure of support for service users so that all service users, however complex or serious their impairment, would be able to manage a direct payment. This crucial component was dropped by the advocates of personal budgets, with an eye on cutting costs.
Personal budgets instead were crudely based on using existing and inadequate funding, top-sliced for administration and allocated on a points basis. This consumerist rather than empowerment based approach has shown itself particularly unhelpful in times of large scale public spending cuts, where what most service users are actually experiencing is damage to their rights and quality of life through cuts in benefits, the loss of dedicated social care services, reductions in mainstream public services and ever-lowering ceilings on and access to support through the current means and needs tested social care system.
It is difficult to see how social care will ever respond effectively to individual rights and needs, and how it could be properly integrated with health care unless their funding systems are unified in line with the universalist principles of the NHS and paid for out of general taxation.