Personal health budgets: challenges for commissioners and policy-makers

A timely report from the Nuffield Trust details the background to the current policy on personal health budgets (due to become effective in April 2014) and some important learning for commissioners and policy makers. From next year, clinical commissioning groups (CCGs) will be required to offer personal health budgets to patients receiving continuing health care and to extend this to patients with long term conditions the following year.

Learning from pilot implementations

The report includes learning from the Department of Health-funded pilot projects across 70 primary care trusts, 20 of which were involved in a detailed evaluation. The evaluation, published last year, found personal health budgets to be generally cost-effective (high value budgets were more cost effective than low budgets) with high compliance; the concept is also supportive of self-management and patient-centred care. Care-related quality of life and psychological wellbeing were higher in patients assigned personal health budgets in the pilot; however, clinical outcomes were no different. A&E and GP costs were also lower; however, total costs were no different (as services were not decommissioned). It should be noted that the scope of the pilot was relatively small (around 1000 people – 56,000 people are currently eligible for continuing health care) so there are some limitations to the lessons learned; it is also possible that issues associated with wider implementation have not been identified.

Commentary

The report makes valuable reading for commissioners in identifying some important issues and challenges which need to be addressed:

Personal health budgets are an opportunity for integration using a “dual carriageway” approach

ensuring a wide range of providers for service users to choose from (understanding needs and preferences of service users) without destabilising local healthcare markets – possible solutions include phased approaches and using tools such as CQUINs (Commissioning for Quality and Innovation);
being prepared to decommission services which are not chosen by service users (the numbers in the pilots were such that existing services continued) which will be difficult for community services where block contracts are common;
creating sustainable systems to manage budget setting, care planning (including support in understanding good practice and systems to manage financial and clinical signoff) and monitoring – the option of “piggy-backing” onto existing services (e.g. independent support brokers within local authorities) is suggested. On average, pilot sites spent around £146,000 on infrastructure;
the risk of introducing a “postcode lottery” as implementations and policies will vary from CCG to CCG;
the level of flexibility is critical to success – the pilot demonstrated that where choice and flexibility was limited, the results were much less positive;
the opportunity to work with social care to create an integrated system, termed a “dual carriageway” approach, aligning referral, assessment, budget setting, planning and monitoring processes without the need for restructures; 1 in 8 people in the pilot also received social care funding so this is a significant opportunity and the authors note an important role for Health and Wellbeing Boards;
the importance of reviewing uptake and impact, not only on individuals but on local health economies.

Link

Alakeson V and Rumbold B (2013), Personal health budgets: challenges for commissioners and policy-makers, Nuffield Trust. http://www.nuffieldtrust.org.uk/publications/personal-health-budgets.