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August 12, 2014

Private Eye Issue 1372
Filed under: Private Eye — Dr. Phil @ 7:57 am

Shop till you drop?

Is giving patients with chronic diseases their own health budget to buy the care they need a good idea? It’s certainly got Simon Stevens, NHS England’s new Chief Executive, very excited. Personal budgets for social care have been around for some years, and Stevens believes ‘north of five million patients’ will have a combined personal health and social care budget by 2018. £5 billion will be taken out of the NHS pot and handed directly to patients. What could go wrong?

Very few politicians will dare argue against such a grand scheme to ‘trust the people’, and if the people decide to buy all their healthcare from private providers rather than the NHS, it’ll be the cleverest Trojan horse to get private providers a slice of the NHS cake yet invented. That makes it even less likely that many in either House will kick up a fuss. Around 200 honourable members in the Lords and Commons voted through the Health and Social Care Act knowing the private health companies they have an interest in could benefit. None had the ethics or insight to abstain.

Personal budgets in health have been piloted in England only on a small scale and the PHB website has lots of heart-warming stories of patients with chronic diseases and disabilities who have benefited by, say, getting the physiotherapy, nursing or counselling care they need, when they need it.

In social care, patients are allowed to employ their own carers and take them into the NHS. As one Eye reader wrote: ‘‘I have a degenerative neurological condition and I’m completely bedridden.  My diet is mostly fluid (I have a peg into my stomach) and I’m fortunate in that I receive Direct Payments from social services to fund my team of carers (that was a battle with social services… drove them potty but I knew what my rights were). My support workers always accompany me on admissions to hospital, otherwise I’d never receive the assistance I need as the wards are so understaffed. They are my advocates and they keep me safe and speak up for me in the NHS”

Stevens, and the government, believe that giving patients combined health and social care budgets will keep them healthier, happier and more independent in their homes and this will reduce hospital admissions, therefore compensating for the £5 billion that may be taken out of the NHS to pay for the scheme. It would be easy to set up a trial to prove this. Recruit a few thousand patients who are eligible for personal health budgets, split the group in half and randomly assigning them to either get a budget or not. Then follow them all up to see if the people with their own budgets have fewer hospital admissions. Sadly this has not yet been done. Research and reform rarely go arm in arm in the NHS. Enthusiastic ideology nearly always trumps evidence.

The experience in social care is that early adopters of the scheme get a healthy budget and do very well, to make it look a political success, but when you try to roll it out to millions it gets more problematic, particularly as budgets are then squeezed year on year. Also, new layers of bureaucracy – the ‘resource allocation system’ (RAS) – are invented to try to let people know the size of their budget upfront so they can make sensible decisions about how to spend it. This hasn’t worked well in social care and many clients on personal budgets now get either get exactly what they got before and often less, as all social care funding has been cut.

The patients who benefited most in social care opted for direct cash payments, rather than letting someone else manage their budget, and those considering the health budget should choose this option and get in there early – preferably before the election – and before the money is cut back. If people are given excellent advice and support on how best to make complex choices and spend the money, the system could work very well for some. But this support too costs money. And we could enter a world where the health and social care you get depends less on your needs and more on how good you are with the money. And what happens if you overspend?

Universal healthcare is being replaced by a market system on a very personal level, with no evidence base. There will be winners and losers, and you either opt for a budget or stick with an NHS that’s £5 billion poorer. Say yes, and two hundred happy Lords and MPs will be after your business.