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Labour should support personal health budgets

July 26, 2012 9:29 am

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The left has always been strong on protection for the vulnerable but all too often this comes at a high price for those who are on the receiving end of support. The experience of individuals and families who depend on state support is often one of disempowerment and a loss of control. Their lives become shaped by services, dictated by petty rules and regulations and dominated by professionals, with little recognition for their role as experts in their own lives or their goals for what their lives could be. They become defined by the services they use rather than by the people they are.

Labour needs a new conception of the state as a partner rather than a protector, recognising the expertise and assets that individuals have to solve some of their own problems. This is not about withdrawal of the state but a change in the relationship between the citizen and the state, to one in which individuals and families shape the support that they receive to meet their own needs.

This new relationship would be powerfully demonstrated by Labour support for personal health budgets for everyone with a long term condition who wants one. These are conditions like cancer, arthritis and depression that affect the way people live as much as their state of health. Take Claire, as an example. She has significant mental health problems and has been frequently admitted to hospital over the last four years. But being the recipient of over £100,000 of NHS support a year has done little to keep Claire well. With a personal health budget to purchase a laptop, a gym membership and a college course alongside some traditional services, she is managing to stay out of hospital, learn new skills, regain some independence and rebuild her relationship with her family, at less than a fifth of the cost.

Giving individuals with long term conditions greater control of the support available from the NHS through a personal health budget would refocus the NHS away from narrow symptom management to allow individuals to improve their health and wellbeing as they see fit, drawing on professional expertise as necessary but recognising people are experts by experience. Instead of buying services for people, individuals would become purchasers in their own right, forcing the market to respond to their preferences and not the block purchasing of central commissioners. This shift towards partnership between the citizen and the state will be essential in securing the future viability of the NHS as a service free at the point of use, as well as signalling a change in the role of the state.

Vidhya Alakeson is Research and Strategy Director at the Resolution Foundation, writing in a personal capacity.

This article was originally published in the Fabian Society’s Summer edition of the Fabian Review. It forms part of the Fabian Society’s Next State project. We’ll be publishing other articles from the series this week.

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  • http://www.facebook.com/people/Mike-Homfray/510980099 Mike Homfray

    If people want them, then there is a case for personal budgets – its worked well in the case of disabled people with physical impairments, or at least did until the government removed half the money people used to pay for their care.
    However, i would urge caution – there is evidence that in the case of older people and people with mental health problems, that the last thing they need or want is this sort of responsibility, and there have been people only too pleased to ‘help’  whose motivations have been less than positive

    I do think we need to stop thinking that everyone is clamouring for individualisation and choice. Many people just want to know that the service is there when they need it

    • ThePurpleBooker

      People do want individualisation and choice. This is your problem – you are a statist. Not the way forward, I am sorry.

      • http://www.facebook.com/people/Mike-Homfray/510980099 Mike Homfray

        Some people do. But I don’t think they are in a majority, particularly in terms of those likely to have the greatest needs. I think this sort of obsession is largely confined to the assertive and sharp-elbowed, who care little for those who just want to know that they can see the doctor for free and without having to wait on a list for 2 years. And that means the local doctor in the local hospital.

        ‘Choice’ is simply indicative that some people are receiving a substandard service.

        These sort of outdated obsessions will be seen to be the unnecessary dreams of a few and will not be a priority when the cuts really start to bite and when we have to restructure proper public services again.

      • http://twitter.com/mistyblulabour dave stone

        You see this as a way of reducing state provision, I see it as way of minimising corporate influence – funny that.

      • treborc

         And your a fecking Liberal who thinks he can come to labour and some how change it. I know you have a mental health issues pretty obvious, but try getting a personal budget today, and then try to work out all the issues.

        I would say Homfray is a socialist, while your a new labour Liberal who really does need to go home.

  • Topper

    Many of the sick people I have met are scared stiff at having to research and source help and care for themselves, budget their money, and take on responsibility for servicing yet another tier of bills, calls, emails, correspondence et al. Many older people are going to absolutely hate further administrative complications added to their lives by forcing them to manage personal health budgets.

    • Quiet_Sceptic

      There’s also the issue that many of the very sick or very elderly may not have the capability to manage a personal health budget and so it would fall to their family or friends.

      • Topper

        Very true.

        • Timsharp1

          My team works with people who have very difficult mental health problems all of the time. I haven’t come across a patient who can’t with some help use a personal care budget appropriately.

          • Topper

            Is there any evidence that a majority of people affected actually want personal health budgets?

          • treborc

             No lots do not, on the other hand of course we do need help, I’m lucky in having my family around me, lots of people do not.

            And getting help is like getting your teeth pulled.

          • Solange

            I would be more interested in hearing what a collective like the BMA has to say than one individual giving a personal opinion.

          • treborc

            Well I have many time, I know many people who are in the fifties with a mental age of five or six who could not possibly understand this.

            I myself when ill did not want to know it was the social services who stepped in to take it over.

            Not everyone is able to understand the legal ramification of employing somebody, you actually become an employer.

          • Caroline

            If you are a clinician I’m an elephant hang-glider pilot in a Gucci dress.

          • Caroline

            If you are a clinician I’m an elephant hang-glider pilot in a Gucci dress.

  • Joe Farrington-Douglas

    Important neither to reject nor to push this policy without evidence (rather than anecdote, as in this article and the comments). That’s why Labour set up the pilots, presumably. 

    • http://www.facebook.com/people/Mike-Homfray/510980099 Mike Homfray

       There has been some research done, but the experiences of carers and groups working in this area should not be ignored either.

      • treborc

         How about the dam disabled, ask us for god sake we are the ones who have to hire those carers and pay for them we are not asked but we have to work out the payments

  • http://twitter.com/mistyblulabour dave stone

    One way of looking at this proposal is to see it as promoting payments for staying healthy – a bundle of money is handed out (to those who want it) with the expectation that they will then keep themselves out of waiting rooms, hospitals etc. (something for something, one might say).

    There’s a lot to be said for this approach. It may take some time to implement but it could engender a change in attitude (with service users and providers) which will eventually place emphasis on prevention rather than cure. This is not to be sneezed at. With increasing numbers of the population receiving treatment for avoidable conditions* costs are set to escalate, perhaps to an unsustainable level unless something is done. This proposal looks to provide a useful outline of how we might do something.

    *U.K currently spends £3.4 billion a year treating heart disease. Much of this, according to research undertaken by Esselstyn and others in the U.S., is preventable and curable at minimal expense – summary: http://www.huffingtonpost.com/caldwell-b-esselstyn-jr-md/the-problem-with-interven_b_754881.html

  • http://nhsvault.blogspot.com Richard Blogger

    “Labour support for personal health budgets for everyone with a long term condition who wants one”

    Whoa, hold on there. Do you know what the term means? Personal HEALTH budget. At the moment, NHS care (with a few exceptions like glasses, dentistry and prescriptions in England) is free at the point of use. I am proud that Labour created a healthcare system with this principle. In fact, I think Labour should go further, and abolish prescription charges in England and work towards getting rid of dentistry charges.

    If you are talking about a Personal HEALTH Budget (as opposed to social care) then you are talking about about monetising healthcare, the very care that we get for free. So while I can (and as a person with a LTC, I do) use my GP and A&E without charge, a PHB will monetise that care. Whether it does so with my money or money from the state is irrelevant because it still makes me a consumer. The most precious feature of our NHS will have gone.

    Now, you may say “but PHBs won’t be imposed for the treatments you mention”. Sure. If that is the case then you are talking about personal social care budgets, which in themselves have problems, but they are different to healthcare budgets. It is the fact that the word HEALTH is inserted in the policy that is the issue, because healthcare at the moment is not subject to a personal budget (ie rationing) and should never be.

    The writer says that a patient was given HEALTH funds to buy a laptop. If it is HEALTH then it will come from the same budget for acute care, electives like cataracts and hip replacements. Can you imagine how the Daily Mail will treat that? At a time of huge cuts to NHS budgets (my local CCG is looking at 8% “savings” next year, that is a huge cut) how will anyone justify giving one person a laptop when another person is told that they are not blind enough for a cataract operation or not in enough pain for a hip replacement? Whatever you think of the benefits of the laptop (and yes, there may be some), a CCG will not be able to make it a priority over an operation like a hip replacement. So please do not give us examples which will not happen in practice. Instead, tell us how PHBs will apply in austerity Britain where NHS care is being cut.

    (Yes some people will say: “but the laptop could save the NHS hundreds of thousands!” I am afraid the NHS looks very short term. For example, most PCTs do not provide DAFNE or DESMOND courses for diabetics even though they have proven to return the cost of the course in a few years through improved management of the patients’ condition. If DAFNE courses were being denied when the NHS was awash with money, do you really think that laptops will be available in times of austerity?)

    Personal budgets in social care have not been a complete success, some people benefit, others don’t. Those who have had a bad experience have been poorly treated. In some cases councils use personal budgets to cut services. A neighbour’s (adult) daughter with learning difficulties has recently been told that the day centre she uses will be closed, and instead she will get a personal budget. What the payment will be for is not clear, but it certainly does not make up for the loss of the facility. I fear that if PHBs become widespread they may become a bucket for payments like these. Perhaps we should first decide what is “personal” (and how that can be delivered) and what is “society” before we move into healthcare consumerism.

    In other cases, people with social care direct payments find it too complicated: they have to become a HR manager (to employ a PA) and a procurement manager to purchase services. As individuals they are not trained to do this, unlike the managers at the council whose job disappears when direct payments are rolled out. Consequently personal budget management companies have sprung up: they take the personal budget and provide the services to the service user while taking a fee. Of course, that is neither “personalised” nor is it cost-effective, and often people have to top-up the budget to pay for services.

    Labour should steer well clear of widespread use of PHBs, when (if) evidence becomes available of PHB benefits then the budgets should be applied cautiously, and only in specific cases when a clear benefit can be achieved. Labour should make it known that under a Labour government those with a personal budget imposed by this government, and who no longer wants it, can recind their “request”.

    • treborc

       You have said it better then I can and your correct I  tried the personal budgets to get a carer got the money but gave up because I just  found it way to much for me, and you can only pay the min wage, and people are not interested in doing it.

  • http://twitter.com/kb32904 KathyB

    If Ed Miliband & Andy Burnham start down this route, the Labour party will not be back in government in 2015 – guaranteed.

    Why is it so hard to accept that we ‘little’ people want our NHS to remain free to access & available whenever it is needed ?

    I have a longterm, terminal illness. A PHB would not help to keep me well – the medics at the hospital do that – it’s what they were trained to do & they do it just fine.

    • treborc

      well said

  • jaime taurosangastre candelas

    Having read the article, I expected to read in the comments some complete opposition, but in fact I am very pleasantly pleased to be on the same side of the argument “in principle”, even if we may differ on detail, as Mike Homfray and Dave Stone.  It is a pretty rare LL article that can achieve that effect – and perhaps among the three of us there is some discomfort at the thought!  

    The concept to me is fine, and not to my mind at conflict with the “free at the point of care” ethos, although that seems counterintuitive and requires some detailed thinking through the transactional internal budgeting that goes on in the NHS and to which patients are not normally exposed.  For many, it could and would be empowering, and it would help get around some painful frustrations where for example a patient is in favour of something like homeopathy, and the GP opposed (there are other examples of this sort of dichotomy – the one I choose is deliberately stark to make a point).  But there are dangers, as Mike and Dave both point out – some people either don’t wish to or perhaps are not capable of sensibly managing such a budget, and that must be respected.

    There’s also a “marketing” problem, I think.  The word “budget” implies something like “We value your continued life at £100,000 a year.  Go over budget and we would rather you were dead”.  That is a horrifying thought, but to be honest, this sort of assessment does go on.  It is not often expressed in individual Mrs Smith or Mr Jones terms, but rather “South Wales has £6.5 million allocated for some particular type of care for the financial year, which we expect to treat 500 individuals.  If we get 550 cases in the year, then we will need to re-budget or scale back on more expensive treatment”.

    A point of detail:  I do not believe this would, or should, be applied to emergency care or to short term or unexpected conditions.  If it is confined to specific long term conditions, then I think it should be trialled.  If it ever became applicable to the entire NHS, it would be a tragedy.  But I do not get the sense that the author intends that.

  • James

    Everybody is gassing authoritatively about what the sick and vulnerable want but has anybody actually asked them? KathyB is one such person who doesn’t. Before we rush ahead and tell the vulnerable and the sick what they want in our opinion is there any evidence whatsoever that such citizens are clamouring for personal health budgets?

    If your personal health budget runs out leaving you in desperate need what then?

    • Ranter

      You mean just like they did when they brought ATOS and the Work Capability Test and ESA in and such like. Ask? Oh come on! Anybody would think you thought politicians were compassionate and honest individuals or something.

  • Timsharp1

    I have worked on and off as a clinician in the NHS since 1981. Essentially the NHS is a nationwide insurance scheme where premiums are based on income and business activity rather than health risk. I probably pay (in my income tax) three times what a very good health insurance scheme would cost me which is expensive for what I get but on the other hand as a child I benefitted from full health coverage even when my parents were on modest incomes so I accept that some of the money that I pay covers the healthcare of people who may be in similar circumstances now.  My dental and optical care is all private (insured and out of pocket).  I do think that giving people choice over how they buy in their own healthcare with their own budgets is basically a good thing in most circumstances. In most parts of the world (with good healthcare coverage) the ability to make a choice about who you want to provide your healthcare is absolutely normal. Labour should support people’s choice, family GPs are in a great position to guide those choices. 

    • Solange

      With NHS cover you get the treatment you need, when you need it, for as long as you need it. If you have to have an organ transplant you receive the surgery, after care, and anti-rejection drugs subsequently indefinitely. The situation is similar with other ongoing chronic conditions. Would private medical insurance provide this level of care to everyone? I ask this because it absolutely doesn’t do so in America where often people end up receiving sub-standard care and cheaper less effective drugs as the HMOs bargain with hospitals to cut the cost of payouts to the lowest levels possible. BUPA may be fine if you need a one-off hip replacement with the NHS picking up the tab for painkillers and so on afterwards, but how is it when it comes to covering a person with a progressive ongoing chronic condition that requires multiple interventions and exotic expensive drugs to manage?  

      • treborc

        If labour plays around with the NHS as they did once before telling us about how great it would be to have  private  services involved, then sadly new labour is not dead and this may well be the reason good old Tony is back, maybe one of his many PR customers wants this.

    • http://nhsvault.blogspot.com Richard Blogger

      “I probably pay (in my income tax) three times what a very good health insurance scheme would cost me ”

      Huh? Your “very good health insurance scheme” will not cover emergency, organ transplant, rare cancers or psychiatric treatment. If you have *any* kind of pre-existing condition, that will not be covered either. In other words the health insurance will not cover anything that is expensive. So it is not possible to compare your tax payments with UK health insurance.

      Yesterday a US friend told me what her insurance payments are: they work out at £5,200 per year for one person. She gets healthcare that she regards as being good. The NHS component of tax spend is about 1/6, (welfare and pensions is the biggest part of tax spend). So you are saying that you pay three times more tax than health insurance? If a comparable health insurance for you is £5200, then considering only 1/6 of your tax goes to the NHS that means you pay £31k in tax. You say that your tax is three times more, so that means you pay £93k in tax. Since tax is about 37% of income that would put you on an income of £250k. We are honoured to have such a wealthy person to come here and tell us what is good for us.

      Now let’s look at someone on average income £25k. That £5k is one fifth their income (and more than their tax, taking the threshold into account). The majority of that £5k will pay for catastrophic cover and to cover the possibility of needing treatment in later life for a chronic condition, in other words, they will not see much of that money spent on them at the time they pay their health insurance. So where is the “choice”? 

      Your devotion ot “choice” is touching. However, in most countries there is no choice. Ask Americans. They will tell you that their insurance means they can only use a hospital or GP that their plan specifies. Sometimes this may mean using primary care in another town because the local GP is not covered. In the UK, we have far better choice of hospital care than most Americans could dream of. In fact before the disastrous internal market was introduced, your GP could refer you to any consultant anywhere in the country. That level of choice would make most Americans swoon. (The internal market, because it depended upon contracts between small fundholding practices and hospitals actually got rid of NHS choice for a decade until the national tariff and NHS choice were introduced in 2006.) 

      • Crixus

        Another fantasy doctor by the look of things. There’s a few like that on this site.

        • treborc

          Why these people even come here is a wonder, after all labour means nothing to them, new labour might of course

  • treborc

    I was given a payment by the council after being accessed £23,000 personal payments to hire a carer for twenty  four hours, as you can see £23,000 is not a lot when you have to have two people pay them, pay insurance stamps, and holiday pay, you can of course get a company do it for you at a cost. In the end my grandson does the lot for me helping me in and out of the bath, getting me out of bed and helping me when I cannot get up for nothing.

    I do not think these personal plans are much good and labour knows it because already over a Billion of money is not claimed for tax credits for pensioners.

    These people never ask the disabled and the sick, they just think we want it

  • http://twitter.com/kb32904 KathyB

    How odd – the same sentiment has been made today in the Telegraph:

    http://www.telegraph.co.uk/health/9431514/Time-to-put-the-NHS-budget-in-the-hands-of-patients.html

    The author of that piece in the Telegraph is Chris Skidmore, tory MP – the same Chris Skidmore that was exposed by Social Investigations at being a panel member in a discussion entitled: Should we abolish the NHS

    Here’s the link – check out the other members of the panel then convince me we aren’t being taken for another ride !

    http://socialinvestigations.blogspot.com/search?q=chris+skidmore

  • halfull2

    Vidhya is absolutely right. Labour introduced personal budgets in social care and the health care pilots. The research in social care clearly shows higher satisfaction and better outcomes. PBs build on and can be taken as Direct Payments – campaigned for by disabled people who were fed up having to take what they were given (the original campaigners were placed in residential care). We shouldn’t be afraid of this or see it as the thin end of the market wedge. It is not the state rowing away from its responsibilities but rather delivering on these in a way that treats people as citizens not supplicants.  

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