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Taking it personally

Taking it personally
3 September 2014

Giving patients with long-term conditions control of their own health budgets can improve outcomes and save money

Giving patients with long-term conditions control of their own health budgets can improve outcomes and save money
One of the biggest challenges to the NHS is that ‘making people better’ isn’t always an option, and how we support people to live well and manage their chronic, often multiple, long term conditions is something we can still do much to improve. Estimates have suggested that almost three million people could have three or more long term conditions by 2018.1 We believe that offering people more control and flexibility over their care is something that can be achieved by offering personal health budgets.
Personal health budgets were piloted at sites across England between 2009 and 2012, and the robust, peer reviewed evaluation demonstrated some positive outcomes for patients and the NHS. When budgets were introduced well, people appreciated more control and flexibility in how their care was delivered, experiencing a better quality of life and an overall reduction in hospital costs. This can also be seen in surveys of budget holders and carers who have experienced an improved quality of life.
The pilot was followed by an announcement from Norman Lamb, Minister of State for Care and Support, that people eligible for NHS Continuing Healthcare (CHC) would be offered a ‘right to ask’ for a personal health budget from April 2014, which was later strengthened by a ‘right to have’ by October this year. The pilot showed that people with higher needs, and therefore a larger budget, were more likely to benefit from the flexibility of managing their care more proactively. 
The logistics of CHC funding made this an ideal service area to start introducing personal health budgets, with the NHS taking on all responsibility for providing care for the individual once assessed as eligible, getting over some of the difficulties of calculating integrated, capitated budgets.
That isn’t to say that introducing personal health budgets to this cohort of people is easy, and the NHS England personal health budget delivery team was set up to support clinical commissioning groups (CCGs) and their support organisations to make budgets a reality for their population. Over the past year we have run the accelerated development programme (ADP), a series of six training days running over six months at locations across England. With over 170 CCGs having already taken part, and a second wave of training sessions just starting, we know that people have found the course helpful in putting the theory into practice, and talking through the complexities of real life scenarios. In addition there is a range of regional and national support, including our restricted access learning network where NHS professionals can discuss some of the thornier decisions and dilemmas, as well as share what’s working well.
Following the pilot, nine areas pledged to lead the way by ‘Going Further Faster’, helping explore how to introduce personal health budgets at scale beyond CHC. Four areas are looking at how to introduce personal health budgets in children’s continuing care and a further six areas are mental health demonstrator sites exploring how personal health budgets could be offered to people using mental health services within existing budgets.
Moving beyond offering budgets within NHS CHC does involve further complications. Personal health budgets are not ‘new’ money, but a shift towards a different way of commissioning services directed by the individual service users rather than ‘service led’ block contracts with providers. While this presents practical and operational challenges to the current models of block contract commissioning, it offers an alternative approach for exploring care pathways where improvements can be made.
In some of the areas that have been ‘Going Further Faster’ to introduce budgets beyond CHC, there have been some great examples of using personal health budgets in areas where the current pathway and funding model could be improved.
As an original pilot site, NHS Dorset CCG has already administered almost 300 personal health budgets to adults eligible for NHS continuing healthcare, children eligible for continuing care, carers under stress, individuals with acquired brain injury and groups of mental health service users.
The brain injury rehabilitation work is a great example of how commissioners can look at using personal health budgets pragmatically as a solution to a care pathway that isn’t working well. It is the provider organisation, Dorset HealthCare University NHS Foundation Trust, that has driven the availability of personal health budgets by working with the CCG so that patients can be offered a more flexible rehabilitation package with speedier discharge from hospital and therapies available from home.
Roger Webb, from Dorset CCG said “The NHS works fantastically well most of the time, but that doesn’t mean we can sit back and carry on delivering services in the same way. The work that we’ve done to improve the rehabilitation offer for people with brain injuries has worked because it’s been collaborative. As commissioners we have learned from the experiences of patients and frontline healthcare staff and responded to that in a way that means people can have a flexible recovery plan”. 
Following a brain haemorrhage in 2011, 20-year-old Tom was one of the first people in Dorset to benefit from this new rehabilitation package. Tom lives on a farm with his family, and was keen to return home as soon as was possible. The community rehabilitation team would normally have struggled to provide for Tom at his remote farm location and, in particular, a personal health budget enabled an independent occupational therapist and a personal assistant who knew Tom, and the farm environment, to be employed. He was able to use the money for gym membership to build back muscle strength, and his speedy recovery surprised everyone – including his medical team. Within a year Tom was back working on the farm, had started a college course and was able to play five-a-side football again.
Simon Stevens, NHS England chief executive, has strongly indicated his support for personal health budgets with the recent announcement of the Integrated Personal Commissioning (ICP) Programme, inviting applications from local authorities and CCGs that are ready and able to make a serious commitment to pooling funds for high-need individuals, in partnership with the voluntary sector. This is an exciting opportunity to make co-produced personalised care a real option, with people having the chance to explore what they need to stay well – not just for their social care needs, or health needs – but to be seen as a whole person. 
1. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. 2012. Epidemiology of multi-morbidity and implications for health care, research and medical education: a cross-sectional study. The Lancet online.
Giles Wilmore is the director for patient and public voice and information at NHS England.

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