It is likely that people’s lives have been saved thanks to personal budgets, say Gill Ruecroft and Sarahlee Richards
Anne, a mother and grandmother, had been using mental health services for over 10 years and had a history of self-harm and overdosing. In the year before she had her personal health budget, she had made six attempts to end her life, had been a frequent caller to the crisis team, and had a number of inpatient stays in a hospital. Three years ago, Anne became one of the first people to join Northamptonshire’s pilot for mental health personal budgets. In those three years, she has made just one call to the crisis team.
‘Anne didn’t want to keep on trying to commit suicide,’ explains Gill Ruecroft, continuing healthcare and personal health budgets commissioning manager for NHS Nene and Corby clinical commissioning groups. ‘But traditional services did not meet all her needs.’ Anne and her care coordinator had noticed that a 12-week course of clinical psychotherapy had ‘really helped her’ – but, when it came to an end, ‘she fell off a cliff again and was back in hospital’. Twelve weeks was all that the NHS could offer.
Having a personal health budget – which allowed Anne to pay for on-going therapy might, quite literally, have saved her life. She no longer needs to see her care coordinator much any more and she has now reduced her psychotherapy: twice-weekly visits have fallen to once every three weeks.
Northamptonshire was one of the 20 original government personal health budget pilot sites established by Labour in 2009. Personal health budgets are an amount of money that go towards the support of an individual’s health and wellbeing needs. Personal health budgets are planned and agreed between the individual, and/or their representative and their clinician. The personal health budget is then authorised by the local clinical commissioning group. Following an independent evaluation, the success of the pilots led the coalition to begin a national rollout of the scheme in 2012. From October 2014, anyone entitled to NHS continuing healthcare – a package of care arranged and funded solely by the NHS for individuals who are not in hospital but have complex ongoing healthcare needs – has a right to have a personal health budget.
Personal health budgets have led to a shift of power into the hands of service users. ‘It’s a completely different approach’, says Ruecroft. ‘It’s a partnership between the clinician and the person, who is an expert in the impact that the long-term condition has on their life.’ The data collected shows that, while people use about 40 per cent of their budget on direct payments to purchase things they were not previously able to receive, 60 per cent of the budget is still used to buy traditional services, such as a community psychiatric nurse, or occupational therapy. Outside of continuing healthcare provision, personal health budgets are available to a very small number of people.
Although very different from Anne’s, the story of Peter shows a similar positive outcome for personal health budgets. A former member of the armed forces who had become a businessman living in the United States, Peter’s ‘world fell apart’ when he had a stroke which damaged the part of his brain used for remembering things. His marriage broke down and, because he has trouble reading his post, he fell into deep financial difficulties. ‘When I met him,’ Ruecroft recalls, ‘he was completely on his own, severely depressed and he had tried to commit suicide a number of times.’
A personal health budget enabled him to employ somebody for a couple of hours a week to help him pay his bills, and this began his road to recovery. The purchase of a satnav from his budget – his cognitive problems meant that he easily got lost even when driving locally – had a transformative effect. Today Peter drives to national events about personal health budgets – speaking at a national conference last year – as well as visiting stroke groups in different parts of the county. ‘He wouldn’t be able to do any of that without his own satnav, it’s completely changed his life,’ says Ruecroft. ‘It’s also changed other people’s lives because he’s helping other people who have had strokes and he now feels his life has purpose.’ Peter also now delivers personal health budget training to Northamptonshire mental health staff.
Traditionally the NHS can only offer a limited menu of services to people. Ruecroft continues, ‘Some people with long-term complex mental health conditions live chaotic lives and these approaches do not make any sense to the way they live their lives and sometimes fail to meet people’s real needs.’
‘Some people really embrace the idea of the customers and patients taking control and some people find that challenging’
Her CCG colleague, commissioning lead Sarahlee Richards, believes the key is personalisation. ‘It’s about people being part of their community, using their own resources and assets. The sort of things that Peter has purchased has enabled him to meet his own health and wellbeing outcomes in a way that makes sense to him and fits with his life. It is not always possible for traditional services to respond in this way.’ Richards hopes that, when the NHS sees what people are buying to meet their needs and achieve outcomes, traditional service delivery may change.
‘People can be quite nervous about having a personal health budget to start with, taking responsibility for it and providing receipts for purchases,’ reflects Ruecroft. She is confident, however, that this will change over time. ‘We feel that, once people understand personal health budgets and all staff are using a personalised approach, people will be supported to write their personal plans and manage their long-term conditions. They will then gain confidence to manage a personal health budget.’ To assist this the CCGs support a peer network so that those who already have personal health budgets can provide mentoring and advice to those considering them.
There can be resistance to personal health budgets from some healthcare professionals, Ruecroft goes on to say. ‘There’s quite a lot of fear that people won’t need or choose their services any more but, once they understand the benefits for the person, on the whole professionals are really supportive.’ Richards agrees: ‘Some people really embrace the idea of the customers and patients taking control and some people find that challenging.’
Concerns regarding managing risks have been largely addressed. Personal plans are written in partnership with the clinician and the personal health budget plan has to be clinically agreed. There may be an occasion when a person chooses to take a risk, which the clinician finds challenging to agree. Risks and mitigating actions may be discussed at a panel but, if the person still wishes to take this risk and fully understands the implications, it is recorded in the plan. But this occurrence is rare thanks, says Ruecroft, to the good relationships that are developed through this new approach.
A nurse by background, Ruecroft welcomes the fact that personal health budgets are challenging the traditional ‘very directive model’ of healthcare and believes it will lead to better outcomes as clinicians are encouraged to look at the whole person – ‘How they live their life [and] what’s important in their life’. They can then support the person to devise different ways of achieving their health outcomes that fit in with their particular lifestyle.
Not only is there the potential for better outcomes, there is also the prospect that personal health budgets may reduce avoidable costs. The budgets are cost-neutral, consisting only of what would have been spent on traditional care. ‘If the person’s health and wellbeing improves,’ says Ruecroft, ‘which it often does, the budget is adjusted to reflect the change in their needs.’ She emphasises, however, that the personal health budget will also be reviewed and, if necessary, increased if a person’s long-term condition relapses and they need more care.
Richards describes the potential for increasing cost-effectiveness over the longer term through prevention. At present, personal health budgets are offered to people who are in secondary health services. She would like them to be available in primary care. ‘We could then prevent problems by supporting people to manage their conditions and stay well, staying out of secondary services and reducing the use of inpatient beds and calls to the crisis team.’
Richards understands that, for some people with a traditional view of health provision, Peter’s purchase of a satnav may appear a strange way to spend health money. An outcome-based health system, she says, should be about supporting a person to manage their condition and improve their health and wellbeing. On those criteria, few could dispute Peter’s choice.
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Liz Kendall MP is shadow minister for care. Steve Reed MP is shadow minister for home affairs
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Download the full pamphlet, Let it go: Power to the People in Public Services, here
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About:
- Personal mental health budgets were first piloted under Labour in 2009. They play an important preventative role, reducing people’e need to use inpatient or secondary services
- Personal budgets can be used creatively for people to meet their health outcomes
- Personal budgets empower people by supporting them to manage their health and wellbeing in a way that makes sense to how they live their life