This guest post is by Vidhya Alakeson, one of In Control's
associates and Deputy Chief Executive of the Resolution Foundation.
Vidhya is a leading consultant in the personalisation of health and
social care. She is an internationally recognised expert on
personal health budgets and has been closely involved in the
development and implementation of personalisation in the NHS.
In December 2013, CCGs and trusts in 14 places across the
country came together to begin implementing personal health budgets
in mental health. In March this year, the same people met for
the last time to review progress. In the intervening time, a
number of people's lives have changed for the better as a result of
getting a personal health budget. A man from Devon with a history
of overdosing now uses his personal health budget to go on long
coach journeys when things start to get too much and avoid ending
up in hospital. A young woman from Stockport with a history of self
harm and emergency hospital visits has stopped turning up at
A&E without even spending her budget. Being listened to as part
of the planning process - one would suspect for the first time -
was enough to make a change in her life. Another woman has used her
personal health budget to go on walking holidays at difficult times
of the year and found the distraction far more effective than
expensive NHS respite care. For all the stories of success,
however, few places implemented more than a handful of personal
health budgets during the 15 months of the programme, far fewer
than we had expected. Is that success or failure?
When we set up the mental health demonstrator programme, the
expectation was that local areas would implement 50 to 100 personal
health budgets for individuals with mental health problems. Our
thinking was simple: the national personal health budget pilot had
run for three years and described in detail how to implement
personal health budgets. A number of places had already blazed a
trail in mental health and an array of tips and toolkits was
available, making it easy for anyone else to get going quickly. We
were being too simplistic. Yes, there is much more information
available about personal health budgets, how they work and the
basic steps to implement them than in 2009 when the pilot began.
But putting personal health budgets in place is not just a
technical task; it is a cultural one.
Implementing personal health budgets does not involve an
incremental change in how NHS services are delivered. Personal
health budgets are closer to a revolution, turning the established
power structures on their head. Fear and resistance are, therefore,
inevitable, from staff as well as those who use services. People
have to be won over locally and that takes time and effort.
Southwark, for example, wants to offer personal health budgets to
individuals wishing to move out of residential care. As a first
step, they worked through a user-led organisation, Experts by
Experience, to engage potential budget holders and staff in
residential homes to share knowledge and gain basic acceptance for
personal health budgets. It is not a question of success or
failure. Regardless of how many tools there are to hand, the
culture change that has to accompany the implementation of personal
health budgets cannot be easily speeded up.
The other area where things proved to be far more difficult than
anticipated was on the finances. The financial question we wanted
to answer was how to sustain large numbers of personal health
budgets without spending more money. However, it all proved a bit
chicken and egg. Without large numbers of budgets in place, it was
difficult to adapt existing finances to discover how to sustain
large numbers of budgets. This is where the new Integrated Personal
Commissioning programme comes in. It is tackling the financing
question head on as a core requirement. However, the risk of
focusing on technical solutions is that the culture change that
must underpin them gets forgotten. Technical solutions without a
real shift in choice and control to individuals will create
personal health budgets in name only. We have seen this in social
care where a focus on the technicalities of resource allocation
systems led to people having personal budgets but not seeing their
lives change in meaningful ways.
Looking back, when we started the demonstrator programme, we
forgot the old tale of the hare and the tortoise. While it is
tempting to drive forward at speed, slower implementation that
allows the culture change to keep pace ensures a longer and
stronger future for personal health budgets.