"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Monday, 24 October 2011

Personal Budgets

Ideologically I am against personal healthcare budgets. Years ago when I first explained to an American colleague why the NHS was so special I told him: "because whatever condition I have the NHS will give me treatment according to clinical need". Personal budgets go against that principle because it gives a hard cash settlement that specifies how much your condition is allowed to cost. I know that there will be assurances from the government and from Prospect-buying Blairites that no one with a personal budget will be denied care if their budget runs out, but we all know that the whole point of budgets is to give an upper limit beyond which you are not supposed to go: a financial constraint, not a clinical one. We also have to question why, at a time of austerity when the NHS has to save money, the government are forging ahead with a policy that will be more costly to administer and which (if we accept their reassurances) potentially cost more than now? The reason, as we all know, is that personal budgets allows the government to put a limit on what the NHS will pay a limit that the government can lower. This is the first step towards co-pay and top-ups. One third of patients who use the NHS have long term conditions and they use two thirds of the NHS budget; it is statistics like this get management consultants thinking, and their "solution" is personal budgets.

However, Lansley has now promised me a personal budget. I have a stable, but long term condition which means that I am exactly the target for a personal budget. At the Conservative party conference this year Lansley said that personal budgets would start in 2014. The Department of Health spin machine reports:
"People receiving continuing healthcare support from the NHS will have the right to ask for a personal health budget, by April 2014 Health Secretary Andrew Lansley announced today. ... The announcement follows the independent NHS Future Forum report which recommended action to promote personal budgets and implement them within five years to give patients access to tailored services."
So the personal budget programme will start with people who need continuing care (mostly elderly people) from 2014 and then before 2016 everyone with a long term condition (that includes me) will have one. (I do not think "have the right to ask for" means that you can choose not to have a personal budget because running two systems side-by-side will be too expensive and it is clear which one the government prefers patients to use.)

Since I will have to have a personal budget soon I decided to ask my local Foundation Trust what they intend to do to tailor their services for patients with personal budgets. Their reply was "I think personal budgets will be for people needing mental health care". I pursued with my questioning, pointing out what Lansley had said at the Tory party conference. It was clear to me from their response that the Foundation Trust hadn't thought about how it would change in the face of personal budgets, so here is a suggestion.

As a diabetic, I use a range of services, from top to bottom: eye checks to monitor my retinopathy; blood pressure checks (and medication); blood sugar tests (both finger prick glucose testing and HbA1c long term tests); kidney function tests (dipstick urine tests) and checks on my feet to monitor any nerve damage in the extremities. These are services I use at the moment. In the future there will be services treating heart disease and sexual dysfunction.

When I get a personal budget my GP (or a.n.other, it is not clear yet who will adjudicate) will collate the list of conditions I have and the list of preventative treatment and monitoring I need, and using the national tariff he will present me with a figure (in real cash or some made up currency) what my condition will cost every year. I will then be expected to go on a shopping trip with this budget. It is not yet clear whether I will hand my NHS Personal Budget "credit card" to each provider when I use their services, or whether I will "commission" the services off them and hence give an intention of developing a more long term relationship.

Some of the services are naturally primary care services: checks on blood pressure, kidney function and on my feet can clearly be done by a diabetic nurse or a healthcare assistant. Some services could be either in primary care or in hospital, for example monitoring of retinopathy. (Currently I am offered this service by my optician, GP and the local hospital; I choose the latter because I have had haemorrhages and a lot of laser treatment and I would prefer the monitoring to be done by a consultant.) Other services (like laser treatment for retinopathy) will be only provided by a hospital, but there is always the choice of several hospitals.

I do not look forward to the prospect of deciding who does what. This is where the FT can help. The FT could provide a care package. That is, they could put together a collection of services for people with personal budgets which would be a mixture of primary care, hospital care, and community services. These packages should have some flexibility in them (for example, I would prefer to have blood taken at my GP - because it does not involve a bus journey and the hospital does - but I would prefer the diabetologist at the hospital to interpret the results). The idea is to put together a list of services that most people use and provide an advocate who will facilitate the providers to work together for the patient. Such a care package could be put together by a GP, but in this example I will assume it is the FT that designs the package.

The advantage to the hospital is clear, they would be able to make patients aware of their services, and at the very least get some income from the administration fee for helping patients to choose. For the patient there will be an advocate who will help them choose, and will also be there throughout the year to give advice if the patient has a problem with the providers. (For example, if I am told to have my eyes monitored every 6 months and it is now 8 months since my last appointment, the advocate will chase up the appointment for me. If the advocate works for the hospital and the eye monitoring is carried out by the hospital it is more likely that the appointment issue will be resolved.) The advantage for primary care is that they will be able to provide some of the services and with closer working with the local hospital they will; provide such services cheaper.

A care package will be much better for the patient not least because the patient will not have the effort of choosing the services themselves. And the closer working between the providers that a care package will offer will help forge the mythical "integration" that the NHS is seeking.

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