Personal Health Budgets and the promises of personalisation and integration of health and social care services
Increasing choice and control over their care for people with long-term health conditions and disabilities is a commitment which the National Health Service (NHS) in the UK has operationalised through a range of policy initiatives and tools. Among these, Personal Health Budgets (PHB) stand out as one of the most radical for the changes they might imply in terms of both the management and funding of health care services.
A PHB is an amount of money that, following an assessment, is identified as suitable to support the healthcare and wellbeing needs of an individual and that the individual can decide to spend for a range of therapies, equipment and personal care services in line with agreed health and wellbeing outcomes.
PHB have been piloted in the UK between 2009 and 2012 and, since 2014, they are offered to people eligible for NHS continuing health care and there is an expectation that their use will increase among people with long-term conditions, learning disability, autism and mental health problems. Moreover, PHB have been used in the context of end of life care and have recently been piloted in maternity care services.
The present contribution aims at providing a thorough description of the changes that PHB imply in regards to NHS provision and at offering a critical analysis regarding their use as instruments for the personalisation and integration of health and social care services.
Indeed, the promises lying behind the introduction of PHB are, on the one hand, that of giving people more choice and control over the money spent on meeting their health and wellbeing needs and, on the other hand, that of integrating the health and social care components of their support provision. For such promises to be delivered, however, a radical shift in the way services are planned, commissioned and delivered has been envisaged and new roles for communities and the private sector demanded. Moving away from block contracts, multi-speciality community providers, new payment mechanisms, community capacity building and patient activation measures are just few examples.
The proposed contribution will be based on the analysis of policy documents, evidence from evaluation studies and the current debate on PHB and on interviews conducted with professionals from NHS services.
The hypothesis sustaining this work is that the promises of personalisation and integration of health and social care services that PHB are trusted to deliver risk losing their potential if not discussed in relation to the implications PHB might have in terms of furthering the privatisation of NHS services and the individualisation of care interventions, especially in a context of financial austerity.
Such hypothesis is supported by three main considerations. First of all, integration has been one of the main pillars of the Individual Budgets (IB) pilot projects which the Department of Health announced in 2005 and which mainly affected social care services. The evaluation of such experiment reported no progress in regards to the target of integration and, over ten years later, the widespread use of Personal Budgets (PB) to purchase solely social care provision confirms the situation has not changed. Whether budgets are the best way to deliver integration is indeed a questionable point. Secondly, there are lessons to be learnt from social care. Personal Budgets have been introduced and, in 2014, made mandatory in social care without any strong evidence supporting them. While they are now a reality for all social care users, more and more research is pointing at how budgets are not necessary for personalised care practices and alternative person-centred-approaches and tools are being considered. Last point, PHB in the NHS are often associated with other new concepts and models such as that of Social Prescribing and Integrated Personal Commissioning (IPC). These models are gaining momentum but it can be argued that their focus is more that of enabling the voluntary and community sector to respond to some of the needs of patients of primary care services rather than on personalisation and integration.
This contribution will focus on the UK but its relevance will apply to all countries which are adopting similar policies and tools. In the case of Italy, for instance, the use of budgets (Budget di Salute) to support both more personalised and integrated care practices is developing in the health and social care services of different regions. Concluding remarks as to why and how the UK case is relevant in relation to the Italian one will be provided.