Personal health budgets and their evil twin

Like every good comic book hero, personal health budgets have an evil twin. There are personal health budgets as they have been developed through the pilot programme. Then there are personal health budgets as described by people who are, lets say, less than convinced about them.

These ‘evil twin’ personal health budgets involve everyone being given a lump of cash to spend on whatever takes their fancy, and left to fend for themselves. What happens when the money runs out? Obviously that’s it, your money is spent on crystal healing and holidays to the Bahamas and the NHS will have no more to do with you.

The reality, as ever, is less exciting, and more complicated.

Personal health budgets have been trialled primarily with people with ongoing health conditions, with the evidence showing that they’re most effective for people with the highest levels of need. So they’re not for everyone. They are voluntary. People plan, with help if they need it, how the resource can help them meet health needs or outcomes that they’ve agreed with the NHS. They plan in the context of their whole life – which will of course include their family, friends and communities. They might choose services the NHS already provides, as well as things it doesn’t. The plan needs to include good consideration of any risks, and to contingency plan for the kind of occurrences that may happen (eg if someone has a relapsing condition, what happens during a relapse). This is all signed off by NHS staff, who need to agree that the proposals could achieve the outcomes they’re supposed to.

The money can be paid directly into someone’s bank account as a direct payment, but it can also be spent through the NHS, or by a third party. Where it’s a direct payment, generally this is paid in instalments, most usually monthly. Most areas have direct payment support services set up through their Local Authority, which help people to manage their money. There is very little evidence of fraud, either in the pilots, or in the wider use of direct payments in social care. People should be supported to review their care regularly anyway, and all direct payments are financially monitored. So the chances of someone blowing all the money`is not that high.

If someone’s needs change, their budget would be reassessed. If the plan is really not working out, they can go back to traditional services.  No-one would be denied the NHS care they need on the basis of having a personal health budget. So that’s that. Told you it wasn’t exciting.

So, lycra-clad superhero, or goatee bearded doppelganger? As with any caricature, the truth lies somewhere else. The final evaluation report from the pilot programme told us that personal health budgets could improve the lives of thousands of people, but implementing them successfully will be hard work. They are a massively counter cultural innovation that will require real leadership at all levels. They’ll need smart, responsive implementation strategies that don’t lose sight of the experience of the people they’re for, costs and outcomes, and the actual (as opposed to imagined) challenges that lie ahead.

The doctor will tell you what is good for you…


As those of us whose lives involve far too much CBeebies know, a new programme aimed at toddlers called ‘Get Well Soon’ has hit our screens recently. Starring the not unattractive Dr Ranj, and a group of puppet toddlers, Get Well Soon explores common childhood illnesses and health issues. It’s great. During one of the multiple times this was on in our house this week (damn you/thank you Virgin On Demand) the theme song became a permanent fixture in my brain.

Be happy, be healthy and get well soon
‘Cos the doctor and nurse, they know what to do (They do!)
They’ll always take good care of you.

Be happy, be healthy and get well soon.
The doctor will tell you what is good for you.
Be happy, be healthy and get well soon.

It’s those middle lines that jumped out at me. It is what we mainly want from the NHS: we’re ill, we need it sorting, we want someone with expertise to fix it. We’re lucky to have one of the world’s best health systems, we’re proud of the NHS and rightly so.

For some people it’s a bit more complicated though. If you have a long term condition that makes a big impact on your day to day life it’s more difficult for the NHS to support you well. Medication may make a big difference, and some therapies will help but ultimately the doctor can’t cure you. You’re the one trying to live as best you can with it every day. This is not easy –  maybe your health stops you working, makes you more dependent on your family than you want to be, and prevents you from getting out and about. All this will drag you down and further damage your emotional and physical health.

This is a challenge the NHS is trying to rise to, but it can’t do it on its own, and many of the shared care planning approaches being introduced recognise this. These tap into your own expertise about your life and how your health condition affects it. Together with the clinical advice of health professionals you come up with a plan that feels like its yours, not the doctor’s.

Personal health budgets are the version of this I know most about. The added component here is that you get to understand how much money the NHS has available for helping you stay healthy and maintain your well-being, and the plan says how this will be spent. Knowing the money is important because it frees you up to come up with solutions that are outside what the NHS can traditionally offer. It also means that the conversation between the person and the health professional is different, more equal.  So it’s not (all) about the money, but this component of the idea is fairly critical.

The final evaluation from the Personal Health Budget pilot programme is due out soon. Results from anecdotal reports, plus the interim reports already published show that this could work for people.

One of the videos on the pilot programme’s website feature Anita and Trevor from Hull, who were struggling to cope with the effects of Anita’s Huntington’s disease. They say how the original solutions the NHS was able to offer, such as going into a nursing home, or having agency staff coming in to help with bathing, just wouldn’t have worked. By coming up with other ideas based on what Anita liked, and by having control over who did come in to help, Anita is happier, and Trevor feels much less stressed.

There’s also an interview with David, who was able to make a relatively small change to the way the NHS supported him, that has meant he is able to get to work on time.

These people still needed their health professionals to help, but in different ways, and on different terms.

So Doctor Ranj, (and your colleague Nurse Morag) you’re still needed. But as part of a different conversation.

And anyway, you sing songs for toddlers about constipation. That’s a big deal in my house. So you’re still my hero.