Personal Health and Care Budgets

Despite their straitened circumstances, the NHS is never short of ways to extend their bureaucracy. Now it intends to increase the number of people with legal rights to having personal health and care budgets. It has been piloted since 2008 with an interim, inconclusive report in 2012. A final report is due soon but they are not waiting for that. A consultation is now running on expanding the “streams” of those legally entitled to personal health budgets from the current 23,000. Planned expenditure can be paid directly into their bank accounts if they wish. Plans can be either health only, funded by the NHS, or care only, funded by the Local Authority, or “integrated” and funded by both and also any other agencies that can be persuaded to give their time and money and participate.

The concept has merit. Patients and the cared-for have more understanding of the costs involved and the options. Patients and the cared-for like the sense of being in charge and having choices, illusory though that may be. Importantly planning seemed to reduce the time spent in hospitals.

On the other hand, the pilots showed no change in clinical measures, e.g. life expectancy, clinical symptoms and “EQ-5D” (health quality of life) for the “plan” group versus the no-plan control group.

The NHS now intend to expand this scheme to about 100,000 people with continuing/long-term health and/or social care needs. No doubt the NHS will have us all at it in due course. The 2012 evaluation did not take into account the meetings and paperwork involved in assessing individuals in the first place and then keeping the account books and updating the plans thereafter. 

Once assessed as having the right to a plan, if the individual wants one, the expected future health/care needs are planned for an appropriate period and costed. The range of items that can be purchased is wide. It includes aromatherapy, for example. To save the Clinical Commissioning Group/Local Authority having to deal with dribs and drabs of bills, funds can be transferred monthly to the carer’s bank account. As I have a rare but continuing condition that can only be mitigated by betting on horse races, I am putting in for a plan myself. The rules say that if the Clinical Commissioning Group or Local Authority consider the money has been misused, they are entitled to ask (sic) for that money back. But they have to continue to provide the care willy nilly.

The system seems to be fraught with opportunities for administrative error. And if you die with funds in your bank, whose money is it? 

For example, Local Authorities have long funded professional carers but not caring by the, often heroic, family members. The distinction is whether the carer cohabits with the cared-for or not. Not too difficult, you might think, for one’s partner to care for the neighbour and his partner to care for you, at least notionally. While the Local Authority is paying the wages, as is the case today, such naughtiness is minimal but with the cash all handed over to the individuals, it surely will. And how many people will be needed to police all this and put prices on everything the individual gets from the NHS and Local Authorities. Are medicines still to be free for the over 60s? Or should plans include the true costs so that proper comparisons can be made?

If someone with an Integrated Personal Budget moves house, does he or she keep unspent funds? Is a bridging loan provided to cover the gap before the new plan comes into place Perhaps it will become attractive to move a few streets from tight-fisted funders to more generous ones.

I may be underestimating the wisdom of the NHS and the Local Authority bosses who are putting all this together. They talk of the move to individual choice and individual rights but the reality is quite different. The paperwork is organized to fit us all into “streams”. Everyone inside a stream is deemed to be the same but different from everyone outside the stream. We are not being given individual independence but categorized.

My final concern is with handing out a new bunch of “legal rights”. Court cases will follow. Follow this logic and we will have legal rights to “Personal Life Budgets” which will require the government to provide each of us with the wherewithal to cope with life’s problems.

Far simpler would be to require more complex health and social care cases, defined by, say, four or more separate specialisms being involved, to appoint from their ranks the lead professional to ensure that a holistic view is taken. Meetings, where feasible, should include the patient/caree because that sense of being in control and having choices is valuable. Normally the leader should be the professional most involved. GPs are not keen on that idea as they would typically get the leadership role and have to add that to their already heavy loads. Some reward would be appropriate. Such a system would cost far less than personal budgets and no bureaucracy would be needed. 

The consultation on the NHS England website runs until 8th June. Please take part. You will soon get a sense of the quality of analysis behind it.