You know the best thing about the Personal Health Budgets evaluation? No, no, not that its the biggest control trialled research on the subject internationally. Nope, not that it showed that personal health budgets resulted in better outcomes for people. Not even that it showed that they reduced use of other health services, or were cost effective. (But they were good answers, well done.) It’s that it identified the components for success, that if you implemented them in one way people get the benefits, and introduced in a different way, they are not worth doing. It’s 160 pages of thorough detailed academia, full of means and medians, ‘bootstrap analysis’ and scatter graphs that make my head spin, but somewhere in there it just about says, in smooth George Michael tones:
“if you’re going to do it… do it right”
This is gold dust. The individual budgets evaluation, which was taking place as personal budgets were introduced in social care, did alot of useful things, but it didn’t do this. In its quantitative analysis it reported on results from the 13 pilot sites as if they had all taken the same approach. This would have been just the ticket if personal budgets were a straight forward ‘intervention’ that could be introduced identically everywhere, rather like a new pill developed in a lab. But of course, it’s not that simple to introduce personal budgets. Both pilot programmes have started with the majority of sites at a standing, or near-standing start, and have not been too prescriptive about how or even what to set up. They were all driven by different people, differently. Each experienced the usual setbacks and resistance, breakthroughs and flashes of inspired leadership. That’s par for the course when trying something very new and potentially radical in a pressured and complicated environment.
So while the individual budgets evaluation gave us a wealth of helpful information, it was even more valuable that the personal health budgets research was able to dig down a bit deeper. And the most important factors in whether a personal health budget worked well? That people knew the budget upfront, had flexibility in what they could spend it on, and could choose how it was managed. Not giving people real choice and flexibility over what the budget could be spent on actually resulted in worse outcomes for budget recipients than the control group.
This doesn’t seem like rocket science, but, as the varied roll out of personal budgets in social care shows, you can be pretty sure that it will be these things that will be under pressure as personal health budgets do become more widespread. And if the pilot programmes were bumpy rides, then making them a mainstream part of NHS provision is fraught with potholes, potential wrong turns and dead ends.
The research report also matched the way personal health budgets were implemented with the attitudes and organisational values of those piloting them. There are a number of different ways to conceptualise personal health budgets, and these will affect decisions about how they are introduced. At one end of the spectrum they can be seen as an extension of shopping – a way for people to exercise more choice and use their consumer clout to buy different stuff. Or they can be seen as a way to give people a chance to think more broadly about the ‘natural wealth’ in their lives – their strengths, opportunities, relationships and communities- as well as their budget. They can use all these together to decide what outcomes matter most to them and make changes that maintain their health, or lessen the impact of ill health. The latter requires a more transformational change in the way services and health professionals work with people, and an implementation strategy anchored in principles and values, as well as the necessary process change. But, strong indications from the personal health budget evaluation, and our learning from social care, tells us that this is the route to getting good results.
As stories like Pete and Michelle’s show, personal health budgets can make a tremendous improvement to a family’s life. But a change rooted in values and new ways of thinking is difficult to achieve, isn’t it?
One thing that is helpful here is the policy position – from April 2014 people in receipt of NHS Continuing Healthcare funding will have a right to ask for a personal health budget. And the government’s mandate to the NHS Commissioning Board sets out a 2015 commitment for people with long health physical and mental health needs who would benefit to have this option. There’s nothing to stop CCGs doing this earlier, and some of the more leading edge places are voluntarily making them available now.* The fact that personal health budgets will be demand led, by people who want them, or by those areas who are genuinely committed to them, should help ensure that they don’t become target- or top-down driven.
The other thing that project managers in some of the advanced sites are finding well worth investing in is the leadership of people getting personal health budgets. A growing number of the projects have set up peer networks. The groups help them steer their projects, begin to build support networks for future budget recipients and serve as allies in explaining what its all about and making things happen.
There is a vast amount of change and restructuring happening throughout the NHS at the moment, particularly amongst managers. The one constant in all this change is people who need support from the NHS and their families. It makes sense that if we’re anxious about the innovation getting corrupted, and losing its values and vision, that it is held and protected by the people who have the biggest stake in the way the system implements it. In Wham!’s own version of ‘nothing about us, without us’:
“if you’re going to do it, do it right, right…do it with me”
*its already lawful to offer a personal health budget approach using a 3rd party or notional budget, and when proposed legislative changes being consulted on now comes into force, everywhe will have the power to make direct payments. Places who were part of the pilot programme may already have these powers.